Abdominal pain in a man with an endovascular aortic prosthesis

A 79-year-old man with an abdominal aorta aneurysm (AAA) with endovascular repair presented with abdominal pain and inflammation. Although the initial work-up was in favour of an idiopathic inflammatory AAA, FDG-PET imaging showed atypical irregular uptake. Per-operative assessment and culture of pus matter revealed infection by Listeria monocytogenes. Atypical findings on imaging of aortic wall inflammation should alarm the clinician of an infectious aetiology.</p

Treatment of patch infection after carotid endarterectomy:a systematic review

Carotid endarterectomy (CEA) with patch angioplasty is a widely used method for treating carotid artery stenosis. Patch infections are extremely rare, but the consequences may be serious. The current gold standard for treatment is patch excision and reconstruction with autologous material. However, no consensus has been reached and other options may be valuable as well in certain cases. The objective of this study was to evaluate the various treatment options for carotid patch infection after CEA with patch angioplasty on the basis of their outcomes (reinfection, ischemic stroke, and infection-related mortality). This systematic review was conducted in accordance with the PRISMA statement. The electronic bibliographic databases PubMed, Cochrane, and EMBASE were searched. Case series and case reports were included. Studies in languages other than English were excluded. Patients who developed a post-operative patch infection of CEA with patch angioplasty were included. Angioplasty could be performed with any type of patch. Patch infection needed to be confirmed by clinical presentation in combination with imaging, culture, or during the operation. The primary outcome measures were reinfection, ischemic stroke, and infection-related mortality. Eleven retrospective case series, two prospective case series, and seventeen case reports were included. The study size was 165 patients (mean age 69.7 years, M/F ratio 1.75:1). One hundred and seventy-one patches developed a patch infection after CEA with patch angioplasty and needed treatment. Treatment strategies included conservative treatment (14.0%), endovascular treatment (4.7%), and open surgery (81.4%). Mean follow-up was 34.8 months and extended up to 180 months. Reinfection rate was 4.7%, ischemic stroke rate 5.8%, and infection-related mortality rate 2.3%. No statistical comparison between treatment options could be performed, because of the heterogeneity of the included studies. Autologous material should be the primary choice of treatment if patch infection is diagnosed after CEA with patch angioplasty. In emergency situations, endovascular treatment, carotid ligation, or abscess drainage could be considered. Endovascular treatment and abscess drainage are temporary solutions. After the patient has recovered sufficiently, a more durable treatment i.e., open surgery is advised. Endo vacuum assisted closure (EndoVAC) seems to be promising. Further research is needed to determine the applicability of each treatment option.</p

Patch angioplasty during carotid endarterectomy using different materials has similar clinical outcomes

OBJECTIVE: Patch angioplasty during carotid endarterectomy is commonly used to treat carotid artery stenosis. However, the choice of which patch to use is still a matter of debate. Autologous venous material has disadvantages such as wound-related problems at the harvest site and a prolonged intervention time. These limitations can be bypassed when synthetic or biological patches are used. Both materials have been associated with divergent advantages and disadvantages. Therefore, the aim of our study was to compare the long-term follow-up outcomes in patients who received carotid endarterectomy and closure with either bovine pericardial patch or polyester patch. METHODS: A retrospective cohort study was conducted, including all patients who underwent primary carotid endarterectomy and closure with bovine pericardial patch or polyester patch between January 2010 and December 2020 at our tertiary referral center. In 2015, bovine pericardial patch was introduced as an alternative for polyester. The primary outcome was the occurrence of transient ischemic attack or cerebrovascular accident during follow-up and secondary outcomes included restenosis, reintervention, all-cause mortality, and patch infection. Cox proportional hazard models were utilized and hazard ratios with 95%-confidence interval were used to predict the above-mentioned outcomes. RESULTS: 417 carotid endarterectomy patients were included. 254 (61%) patients received bovine pericardial patch and 163 received (39%) polyester. The mean age was 70.2 ± 8.7 and 67% were male. The median follow-up time was 15 (12-27) months for bovine pericardial patch and 42 (16-60) months for polyester (p<0.001). Postoperative hematoma (≤30 days) was significantly lower in the bovine pericardial patch cohort (2% bovine pericardial patch vs 6% polyester; p=0.047). No other significant differences on short-term outcomes were found. Univariable cox regression analyses showed no significant differences between the effect estimates of polyester and bovine pericardial patch on transient ischemic attack or cerebrovascular accident (p=0.106), restenosis (p=0.211), reintervention (p=0.549), and all-cause mortality (p=0.158). No significant differences were found after adjusting for confounders in the multivariable analyses: transient ischemic attack or cerebrovascular accident, (p=0.939), restenosis (p=0.057), reintervention (p=0.193) and all-cause mortality (p=0.742). Three patients with a polyester patch had patch infection compared to none of the patients in the group who received a bovine pericardial patch. CONCLUSION: This large retrospective study showed comparable safety and durability of both bovine pericardial patch and polyester suggesting that both patch types can be safely applied for carotid endarterectomy with patch angioplasty. Patch infection was rare while absent in the bovine pericardial patch group

Use of Omniflow® II Biosynthetic Graft for the Treatment of Vascular Graft and Endograft Infections

Background: Vascular graft/endograft infection is a rare but life-threatening complication of cardiovascular surgery and remains a surgical challenge. Several different graft materials are available for the treatment of vascular graft/endograft infection, each having its own advantages and disadvantages. Biosynthetic vascular grafts have shown low reinfection rates and could be a potential second best after autologous veins in the treatment of vascular graft/endograft infection. Therefore, the aim of our study was to evaluate the efficacy and morbidity of Omniflow® II for the treatment of vascular graft/endograft infection.Methods: A multicenter retrospective cohort study was performed to evaluate the use of Omniflow® II in the abdominal and peripheral region to treat vascular graft/endograft infection between January 2014 and December 2021. Primary outcome was recurrent vascular graft infection. Secondary outcomes included primary patency, primary assisted patency, secondary patency, all-cause mortality, and major amputation.Results: Fifty-two patients were included with a median follow-up duration of 26.5 (10.8–54.8) months. Nine (17%) grafts were implanted in intracavitary position and 43 (83%) in peripheral position. Most grafts were used as femoral interposition (n = 12, 23%), femoro-femoral crossover (n = 10, 19%), femoro-popliteal (n = 8, 15%), and aorto-bifemoral (n = 8, 15%) graft. Fifteen (29%) grafts were implanted extra-anatomically and 37 (71%) in situ. Eight patients (15%) presented with reinfection during follow-up, most of these patients received an aorto-bifemoral graft (n = 3, 38%). Intracavitary vascular grafting had a 33% (n = 3) reinfection rate and peripheral grafting 12% (n = 5; P = 0.025). The estimated primary patencies at 1, 2, and 3 years were 75%, 72%, and 72% for peripherally located grafts and 58% (at all timepoints) for intracavitary grafts (P = 0.815). Secondary patencies at 1, 2, and 3 years were 77% (at all timepoints) for peripherally located prostheses and 75% (at all timepoints) for intracavitary prostheses (P = 0.731). A significantly higher mortality during follow-up was observed in patients who received an intracavitary graft compared to patients with a peripheral graft (P = 0.003).Conclusions: This study highlights the efficacy and safety of the Omniflow® II biosynthetic prosthesis for the treatment of vascular graft/endograft infection, in absence of suitable venous material, with acceptable reinfection, patency, and freedom of amputation prevalences, especially in replacing peripheral vascular graft/endograft infection. However, a control group with either venous reconstruction or another alternative graft is needed to make firmer conclusions.</p

Patient-Tailored Approach for Diagnostics and Treatment of Mycotic Abdominal Aortic Aneurysm

Background: The existing literature on mycotic aortic aneurysm is scarce and focuses on treatment. This study evaluates the clinical characteristics, diagnostics, treatment and outcome of patients with a mycotic abdominal aortic aneurysm treated in a tertiary referral center. Methods: A retrospective cohort study was conducted including all patients with a proven mycotic abdominal aortic aneurysm admitted between May 2010 and July 2020. Primary outcome was mortality and secondary outcome included complications such as vascular graft/endograft infection. Results: Twenty-four patients with a mycotic abdominal aortic aneurysm were included. Patients had a mean age of 68 +/- 9 years and 20 (83%) were male. Thirteen patients (57%) had positive preoperative blood cultures. Streptococcus pneumoniae was most frequently isolated by blood culturing, pus, and vascular, or perivascular tissue cultures (17%). In 19 (83%) patients the mycotic abdominal aortic aneurysm was located infrarenally, in three (13%) patients suprarenally, and in one (4%) patient juxtarenally. Median follow-up was 20 (7-42) months. In 8 patients (33%) vascular graft and or endograft infection was diagnosed after surgical repair. Ten (42%) patients died during the follow-up period. The main causes of death were vascular graft/endograft infection-related (n = 4) and rupture of the mycotic abdominal aortic aneurysm (n = 3). No patient characteristics could be identified as predictive for mortality. Conclusions: This study shows a large variation in presentation, diagnostic approaches, and surgical and antibiotic treatment of mycotic abdominal aortic aneurysm. The detailed information about the diagnostic approaches to this rare disease and its antibiotic and/or other treatment contributes to existing knowledge of mycotic abdominal aortic aneurysm. Because of the individual variation patients should be discussed in a multidisciplinary team with a vascular surgeon, infectious disease specialist, and clinical microbiologist