Lutz Brigitta, Reeps Christian, Biro Gabor, Knappich Christoph, Zimmermann Alexander, Eckstein Hans-Henning
Department of Visceral, Thoracic, and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany; Department of Vascular Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.
Department of Vascular Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.
Ann Vasc Surg. 2017 May;41:118-126. doi: 10.1016/j.avsg.2016.07.098. Epub 2016 Nov 27.
Alloplastic aortic graft infection is a devastating complication following aortic surgery. It is associated with excessively high mortality and morbidity caused by anastomotic rupture or septicemia. Many authors consider in situ replacement after complete surgical graft removal as the method of choice. However, there is an ongoing debate about the most suitable material for reconstruction. We present our first experiences with replacing the descending and infrarenal aorta using custom-made bovine pericardium grafts.
From January 2013 to 2015, 13 patients (10 male, median age 70 years, range 53-84) were treated for 5 early-graft infections after open reconstructions and 7 late graft infections (1 TEVAR, 2 EVAR, and 4 open reconstructions), and 1 patient was treated for mycotic aneurysm. Septicemia was evident in 8 patients, whereas 5 patients were presented with low-grade infection. In all cases, graft infection was proven by a synopsis of clinical findings, laboratory tests, imaging, and microbiologic tests (positive pathogen detection in 11 patients). Cutaneous and aortoenteric fistulae were present in 3 and 4 patients, respectively. All patients received an in situ replacement using a hand-sewn xenoprosthesis or patch made from a bovine pericardium sheet. Follow-up was routinely performed 3, 12, and 24 months after discharge.
For reconstruction, 4 pericardium tubes, 7 bifurcated grafts, and 2 large patches were implanted in situ. Technical success was 100%. Median length of hospital stay was 44 days (range, 20-136 days), with an in-hospital mortality rate of 7.7% (n = 1). Major procedure- and disease-related complications were temporary (n = 2) and permanent dialysis (n = 1), limb loss (n = 1), and long-term ventilation (n = 5). Complete infection control and initial healing could be achieved in 75% (n = 10). During the follow-up (median 9 months, range: 1-27 months), primary graft patency was 100%, and mortality was 41.7%. We observed 2 secondary ruptures due to reinfection at 4 and 7 months.
Custom-made bovine pericardium grafts provide a good option for in situ replacement following early or late aortic graft infection. Despite of its high biocompatibility, pericardium provides not an absolute protection against ongoing retroperitoneal infection. For the treatment, the principles of septic surgery need to be applied and close follow-up is mandatory.
人工血管主动脉移植感染是主动脉手术后一种毁灭性的并发症。它与吻合口破裂或败血症导致的极高死亡率和发病率相关。许多作者认为在完全手术移除移植血管后进行原位置换是首选方法。然而，关于最适合重建的材料仍存在争议。我们介绍了使用定制牛心包移植物置换降主动脉和肾下腹主动脉的初步经验。
2013年1月至2015年，13例患者（10例男性，中位年龄70岁，范围53 - 84岁）接受治疗，其中5例为开放重建术后早期移植物感染，7例为晚期移植物感染（1例胸主动脉腔内修复术，2例腹主动脉腔内修复术，4例开放重建术），1例为真菌性动脉瘤。8例患者有明显败血症，5例为轻度感染。所有病例均通过临床检查、实验室检查、影像学检查和微生物学检查确诊移植物感染（11例患者检测到阳性病原体）。分别有3例和4例患者出现皮肤瘘和主动脉肠瘘。所有患者均使用手工缝制的异种生物假体或由牛心包片制成的补片进行原位置换。出院后常规在3个月、12个月和24个月进行随访。
为进行重建，原位植入了4根心包管、7个分叉移植物和2个大补片。技术成功率为100%。中位住院时间为44天（范围20 - 136天），院内死亡率为7.7%（n = 1）。主要的手术和疾病相关并发症包括临时（n = 2）和永久透析（n = 1）、肢体缺失（n = 1）以及长期通气（n = 5）。75%（n = 10）的患者实现了完全感染控制和初期愈合。在随访期间（中位9个月，范围1 - 27个月），原发性移植物通畅率为100%，死亡率为41.7%。我们观察到4个月和7个月时因再次感染出现2例继发性破裂。
定制牛心包移植物为早期或晚期主动脉移植物感染后的原位置换提供了一个良好选择。尽管心包具有高生物相容性，但并不能绝对防止腹膜后持续感染。对于该治疗，需要应用感染性手术原则并进行密切随访。
