Chiesa R, Astore D, Frigerio S, Garriboli L, Piccolo G, Castellano R, Scalamogna M, Odero A, Pirrelli S, Biasi G, Mingazzini P, Biglioli P, Polvani G, Guarino A, Agrifoglio G, Tori A, Spina G
Cattedra di Chirurgia Vascolare, Università Vita e Salute, IRCCS H. San Raffaele, Milano, Italy.
Acta Chir Belg. 2002 Aug;102(4):238-47. doi: 10.1080/00015458.2002.11679305.
Vascular prosthetic graft infection remains a major surgical challenge. Prevention of risk factors and antibiotic therapy can reduced but not eradicate it. Management of infected vascular grafts depends on several factors, including the location of the infected prosthesis, the extent of infection, and the underlying micro-organism. Classic treatment consists of extra-anatomic bypass grafting. The disappointing results due to the high mortality and amputation rate have kindled interest in alternative approaches, such as in situ reconstruction with antibiotic-bonded prostheses, autogenous veins or arterial allografts.
We focused on the treatment of aortic graft infection by means of both fresh and cryopreserved arterial allograft. Here, the experience of the Italian Collaborative Vascular Homograft Group is reported.
Between March 1994 and December 2000 seventy-nine patients with aortic graft infection were treated. The results of 68 patients are analysed. Eleven patients were treated with fresh, and 57 with cryopreserved homograft. Emergency surgical procedures were performed in 12 patients (17%). Aortoenteric fistula was diagnosed in 22 patients. The mean interval between the first procedure and the insertion of a homograft for patients with infected aortic graft was 3 years (range 1-15). The mean duration of follow-up was 30 months (range 1-68). Clinical and duplex scanning evaluation were routinely performed. Computer tomography (CT), magnetic resonance (MR), or arteriography were performed on the basis of duplex scanning results.
The analysis was performed on 68 cases for which there were sufficient reliable data. Eleven deaths occurred during the early postoperative period (30 days), a mortality rate of 16%. There were also seventeen late deaths, a mortality rate of 25%. Eleven patients had graft occlusion; six cases were successfully treated with thrombectomy. In three cases leg amputation was necessary. The results of fresh and cryopreserved homografts were compared. No significant differences of early postoperative mortality, late mortality, homograft-related mortality, graft failure were observed. The presence of aortoenteric fistula is a negative predicting factor of perioperative early mortality, which causes a rapid decline in the survival curve. Thirty-six months after the surgery the actuarial survival of the patients was 57% and the actuarial patency of the allograft was 41%.
No significant difference in terms of clinical outcome was observed when using fresh, rather than cryopreserved homografts. The only factor that significantly influenced the survival rate appeared to be the aorto-enteric fistula.
血管人工移植物感染仍然是一项重大的外科挑战。预防危险因素和抗生素治疗可降低感染率，但无法根除感染。感染血管移植物的处理取决于多个因素，包括感染假体的位置、感染程度以及潜在的微生物。传统治疗方法包括解剖外旁路移植术。由于高死亡率和截肢率导致的令人失望的结果引发了人们对替代方法的兴趣，例如使用抗生素结合假体、自体静脉或动脉同种异体移植物进行原位重建。
我们专注于通过新鲜和冷冻保存的动脉同种异体移植物治疗主动脉移植物感染。在此，报告意大利血管同种异体移植协作组的经验。
1994年3月至2000年12月期间，对79例主动脉移植物感染患者进行了治疗。分析了68例患者的结果。11例患者接受新鲜同种异体移植物治疗，57例接受冷冻保存同种异体移植物治疗。12例患者（17%）接受了急诊手术。22例患者被诊断为主动脉肠瘘。感染主动脉移植物患者首次手术与植入同种异体移植物之间的平均间隔时间为3年（范围1 - 15年）。平均随访时间为30个月（范围1 - 68个月）。常规进行临床和双功超声扫描评估。根据双功超声扫描结果进行计算机断层扫描（CT）、磁共振成像（MR）或动脉造影。
对68例有足够可靠数据的病例进行了分析。术后早期（30天内）有11例死亡，死亡率为16%。还有17例晚期死亡，死亡率为25%。11例患者发生移植物闭塞；6例通过取栓术成功治疗。3例患者需要截肢。比较了新鲜和冷冻保存同种异体移植物的结果。未观察到术后早期死亡率、晚期死亡率、同种异体移植物相关死亡率、移植物失败率的显著差异。主动脉肠瘘的存在是围手术期早期死亡率的负面预测因素，这会导致生存曲线迅速下降。手术后36个月，患者的精算生存率为57%，同种异体移植物的精算通畅率为41%。
使用新鲜同种异体移植物与冷冻保存同种异体移植物相比，在临床结果方面未观察到显著差异。唯一显著影响生存率的因素似乎是主动脉肠瘘。
