Healthcare associated infections in vascular surgery

Health care associated infections (HCAI) affect roughly four million people in Europe annually, resulting in 16 million extra days of hospital stay, 37 000 attributable deaths and direct costs of approximately € 7 billion. HCAI in vascular surgery are relatively common complications with potentially devastating consequences. The aim of this thesis, based on four papers, was to study the scope of these complications and investigate the viability of methods for large-scale follow-up of patients after discharge and potentially more accurate laboratory diagnostic tools for postoperative infections. The first paper, which is also the first of the two epidemiological studies included 10 547 patients who had undergone elective, infrainguinal revascularization – open or endovascular – during the period 2005-2010. Data were collected from the Swedish National Registry for Vascular Surgery (Swedvasc), the Swedish National Patient Register (NPR) and the Cause of Death Register. The total incidence of HCAI within 30 days was 9.7% (n = 1 019). The rate of 30-day HCAI for endovascular procedures was 7.8% (490/6 262) and for bypass operations 13.3% (430/3 224). The rate of major amputation at one-year was 11.8% (98/833) for patients with postoperative HCAI and 5.6% (446/7 933) for those without HCAI postoperatively. The second paper, a prospective, clinical pilot-study, evaluated the effect of surgically induced inflammation on neutrophil CD64 receptors, which have been shown to undergo a rapid upregulation in response to bacterial infection. This study included 153 elective, vascular patients. The results showed a non-significant effect of surgical trauma on CD64 receptors, as well as, a significant increase in CD64 expression postoperatively, in response to bacterial infection. The third paper aimed to investigate some of the cellular responses to surgical trauma and infection by measuring the changes in serum concentration of an array of cytokines in 96 consecutive patients undergoing non-emergent vascular surgery. The results showed a decrease in eight pro-inflammatory cytokines and a positive correlation between perioperative infection and the anti-inflammatory cytokines, interleukin (IL)-10 and IL-13. The fourth paper, which included a similar cohort to the first paper, collected data on 9 894 patients from Swedvasc, NPR and the Prescribed Drug Register, between 2005 and 2010. The aim of this study was to determine the rate and type of postoperative HCAI, after discharge from hospital, using antibiotic prescription as a surrogate marker. We have shown that 33% of patients received an antibiotic prescription within 30 days of the index operation. In the endovascular group, there was a 52% increase in the rate of prescriptions postoperatively compared to the preoperative period. Prescriptions for urinary tract infections dominated the 30-day postoperative period for patients with claudication. The rates of postoperative HCAI after lower limb revascularization warrant a more extensive follow-up regimen, including post-discharge, for both open and endovascular procedures. The need for more accurate laboratory tests in the early postoperative period still remains to be fulfilled. Neutrophil CD64 in combination with other markers, such as IL-10 and C-reactive protein have shown potential in this area and merit further investigation

Case Report Novel Visceral-Anastomosis-First Approach in Open Repair of a Ruptured Type 2 Thoracoabdominal Aortic Aneurysm: Causes behind a Mortal Outcome

Case reports to analyze causes and possible prevention of complications in a new setting are important. We present an open repair of a ruptured type 2 thoracoabdominal aortic aneurysm in a 78-year-old man. Lower-body perfusion through a temporary extracorporeal axillobifemoral arterial prosthesis shunt was combined with the use of a branch to the permanent aortic prosthesis to enable rapid visceral revascularization using a visceral-anastomosis-first approach. The patient died due to transfusion-induced capillary leak syndrome and left colon necrosis; the latter was probably caused by a combination of back-bleeding from lumbar arteries causing a steal effect, an accidental shunt obstruction, and hemodynamic instability towards the end of the operation. The visceral-anastomosis-first approach did not contribute to the complications. This approach reduces the time when visceral organs are perfused only via collateral arteries to the time needed for suturing the visceral anastomoses. This may be important when collateral perfusion is marginal

Deep Femoral Vein Reconstruction for Abdominal Aortic Graft Infections is Associated with Low Aneurysm Related Mortality and a High Rate of Permanent Discontinuation of Antimicrobial Treatment

Objective: Aortic prosthesis infection is a devastating complication of aortic surgery. In situ reconstruction with the neo-aorto-iliac system (NAIS) bypass technique has become increasingly used and is recommended in recent treatment guidelines. The main aim was to evaluate NAIS procedural outcomes when undertaken after previous open or endovascular aortic repair in Sweden. Methods: In this retrospective study, The National Quality Registry for Vascular Surgery (Swedvasc) was used to identify Swedish centres that offered the NAIS bypass procedure for aortic prosthesis infection between 2008 and 2018. Variables of special interest were procedural details, short and long term survival, renal and other complications, and the durtion of antimicrobial treatment. Results: Forty patients (36 males, four females [mean age 69 years], 32 open repairs, seven endovascular aortic repairs [EVAR] and one fenestrated EVAR; 21 presented with aorto-enteric fistula) operated on with NAIS bypass were reviewed. The median time from the primary aortic intervention to the NAIS bypass procedure was 32 months (range 0 – 252 months). Mean ± standard deviation operating time was 645 ± 160 minutes, mean blood loss was 6 277 ± 6 525 mL, mean length of intensive care unit stay was 5.3 ± 3.7 days, and mean length of overall hospital stay was 21.2 ± 11.4 days. Thirty-five patients (88%) had a positive microbial culture; the most commonly isolated pathogen was Candida spp. The majority of patients survived for 30 days (n = 35 [88%]), and 33 (83%) and 32 (80%) patients survived for 90 days and one year, respectively. The number of surviving patients free from antimicrobial treatment at 90 days, six months, and one year was 19 (58%), 29 (88%), and 30 (94%). After a mean long term follow up of 69.9 ± 44.7 months, 20 patients were still alive. Conclusion: The NAIS bypass procedure offered reasonable survival and functional outcomes, and was associated with a high cure rate, defined as freedom from any antimicrobial treatment