Surgical policy in treatment of patients with infected aortofemoral bifurcation allografts

Khamitov F.F., Matochkin E.A., Gadzhimuradov R.U., Kuzubova E.A.

Municipal Clinical Hospital named after V.V. Veresaev, Moscow Healthcare Department, Moscow, Russia

Described in the article are the results of treating a total of 44 patients who endured repeat operations for infection of aortofemoral bifurcation allografts over the period between 2001 and 2018. These patients had previously undergone reconstructive operations using various synthetic grafts for lower limb ischaemia on the background of lower-limb artery atherosclerosis and infrarenal aortic aneurysms. Infection of synthetic vascular allografts in these patients was observed both in the immediate and remote postoperative periods. The dominating infection in 70% of patients was methicillin-resistant Staphylococcus aureus. The main objective risk factors for infection of bifurcation grafts were found to be as follows: stage III-IV chronic lower limb ischaemia (according to the Fontaine-Pokrovsky classification), diabetes mellitus, and prior operations on lower-limb arteries. Two of the 44 patients were operated on for reinfection after repeat aortofemoral bypass grafting. 30% of patients underwent repeat surgery with symptoms of sepsis. After meticulous additional examination and preoperative preparation the patients were subjected to secondary simultaneous operation, i.e., removal of the synthetic aortofemoral bifurcation prosthesis and aortofemoral bifurcation autovenous repeat reconstruction (repeat bypass grafting) in situ. Aortofemoral bifurcation grafts were formed using superficial femoral veins from both legs.

Four patients died in the immediate postoperative period. Other short-term complications included arrosive bleeding with or without sepsis, amputation of one leg due to graft limb thrombosis, and development of peritonitis resulting from perforation of the jejunum. In the remote period, patency of autovenous grafts was confirmed in 37 patients. Of long-term complications, mention should be made of the following: formation of aneurysms of distal anastomoses and thrombosis of one of the limbs of the autovenous graft. The patients were successfully operated on now using synthetic grafts in infection-free conditions.

Hence, a method of surgical decision-making in patients with infected aortofemoral bifurcation grafts is the use of the technique of complete removal of the infected synthetic graft with simultaneous in situ replacement using autovenous grafts from superficial femoral veins, active pre- and postoperative antibiotic therapy. Such policy made it possible to decrease the mortality rate to 9%, with a limb-salvage rate of 97.5% and long-term graft patency rate amounting to 92.5%.

KEY WORDS: atherosclerosis of the aorta and lower-limb arteries, abdominal aortic aneurysm, aortofemoral bifurcation reconstruction, infection of synthetic vascular graft, autovenous repeat reconstruction.

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