Noel Audra A, Gloviczki Peter, Cherry Kenneth J, Safi Hazim, Goldstone Jerry, Morasch Mark D, Johansen Kaj H
Division of Vascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
J Vasc Surg. 2002 May;35(5):847-52. doi: 10.1067/mva.2002.123755.
Aortic reconstructions for primary graft infection (PGI), mycotic aneurysm (MA), and aortic graft-enteric erosion (AEE) bear high morbidity and mortality rates, and current treatment options are not ideal. Cryopreserved grafts have been implanted successfully in infected fields and may be suitable for abdominal aortic reconstructions. Registry data from several institutions were compiled to examine results of cryopreserved aortic allograft (CAA) placement.
The experience of 31 institutions was reviewed for CAAs inserted from March 4, 1999, to August 23, 2001. Indications for CAA, organisms, mortality, and complications were identified.
Fifty-six patients, 43 men and 13 women, with a mean age of 66 years (range, 44 to 90 years) had in situ aortic replacement with CAA. Indications for CAA placement were PGI in 43 patients (77%), MA in seven (14%), AEE in four (7%), and aortic reconstruction with concomitant bowel resection in two (4%). Infectious organisms were identified in 33 patients (59%); the most frequent organism was Staphylococcus aureus in 17 (52%). Thirty-one patients (55%) needed an additional cryopreserved segment for reconstruction. The mean follow-up period was 5.3 months (range, 1 to 22 months). One patient died in the operating room, and the 30-day surgical mortality rate was 13% (7/56). Seven additional patients died during the follow-up period, yielding an overall mortality rate of 25% (14 patients). Two patients (4%) had graft-related mortality as the result of hemorrhage from the CAA and persistent infection. Graft-related complications included persistent infection with perianastomotic hemorrhage in five patients (9%), graft limb occlusion in five (9%), and pseudoaneurysm in one (2%). Three patients (5%) needed amputation.
In situ aortic reconstruction with CAA in infected fields carries a high mortality rate, but most deaths are not the result of allograft failure. However, CAA infection and lethal hemorrhage caused by graft rupture occurs and is concerning. Early reinfection was not reported. Late graft-related complications, such as reinfection, thrombosis, or aneurysmal changes, are unknown. Preliminary data from this registry fail to justify the preferential use of CAA for PGI, MA, or AEE. A multicenter, randomized study is needed to compare results with established techniques.
针对原发性移植物感染（PGI）、真菌性动脉瘤（MA）和主动脉移植物-肠侵蚀（AEE）进行的主动脉重建手术，其发病率和死亡率都很高，且目前的治疗方案并不理想。冷冻保存的移植物已成功植入感染区域，可能适用于腹主动脉重建。收集了几家机构的登记数据，以研究冷冻保存的主动脉同种异体移植物（CAA）植入的结果。
回顾了31家机构在1999年3月4日至2001年8月23日期间植入CAA的经验。确定了CAA的适应证、病原体、死亡率和并发症。
56例患者（43例男性和13例女性）接受了原位主动脉置换并植入CAA，平均年龄66岁（范围44至90岁）。植入CAA的适应证为PGI 43例（77%）、MA 7例（14%）、AEE 4例（7%）、主动脉重建并同时进行肠切除2例（4%）。33例患者（59%）鉴定出感染病原体；最常见的病原体是金黄色葡萄球菌，共17例（52%）。31例患者（55%）需要额外的冷冻保存节段进行重建。平均随访期为5.3个月（范围1至22个月）。1例患者在手术室死亡，30天手术死亡率为13%（7/56）。随访期间又有7例患者死亡，总死亡率为25%（14例患者）。2例患者（4%）因CAA出血和持续感染导致与移植物相关的死亡。与移植物相关的并发症包括5例患者（9%）出现持续感染并伴有吻合口周围出血、5例（9%）出现移植物肢体闭塞、1例（2%）出现假性动脉瘤。3例患者（5%）需要截肢。
在感染区域进行原位主动脉重建并植入CAA的死亡率很高，但大多数死亡并非同种异体移植物失败所致。然而，CAA感染和移植物破裂导致的致命性出血确实发生且令人担忧。未报告早期再感染情况。晚期与移植物相关的并发症，如再感染、血栓形成或动脉瘤样改变尚不清楚。该登记处的初步数据无法证明优先使用CAA治疗PGI、MA或AEE是合理的。需要进行一项多中心随机研究，以将结果与现有技术进行比较。
