Surgical policy and peculiarities of management of patients with infection of an aortofemoral bifurcation synthetic prosthesis
AbstractObjective. This study was aimed at improving the results of surgical treatment of patients with infected synthetic prostheses in the aortoiliac zone by replacing them with an autovenous graft using in situ technique.
Patients and methods. Analyzed herein are therapeutic outcomes in a total of 78 patients who underwent redo surgery for infection of aortofemoral bifurcation allografts over the period from 2001 to 2023. These patients were initially operated on for atherosclerotic occlusion of the terminal aorta and its branches (Leriche syndrome) or aneurysms of the infrarenal aorta. Prosthetic infection was observed both in the immediate and long-term postoperative periods. After confirmation of the diagnosis and preoperative preparation, all patients were re-operated in the scope of aortofemoral bifurcation autovenous prosthetic repair according to in situ technique. Femoral and internal jugular veins were used as autografts.
Results. In the immediate postoperative period, the following complications were encountered: acute renal failure (ARF), multiple organ system failure (MOSF), and arrosive bleeding. Thrombosis of one of the branches of the autovenous prosthesis developed in two (2.5%) patients, one (1.3%) of whom was subjected to high-level hip amputation. Arrosive bleeding was observed in five (6.4%) cases. Perioperative mortality amounted to 15.3% (12 patients).
The remote results were evaluated in 62 patients during a 1-to-12-year follow-up period. Only one patient developed false aneurysms of distal anastomoses, which were operated on successfully. There was no long-term mortality.
Conclusion. Thus, the method of removing an infected synthetic bifurcation graft in the aortoiliac position with simultaneous autovenous redo prosthetic repair using femoral and internal jugular veins can be considered as a method of choice of surgical treatment in patients with suppuration of bifurcation prostheses.
Funding. The study had no financial support.
Conflict of interest. The authors declare no conflicts of interest.
Authors’ contribution. Study conception and design – Khamitov F.F.; data collection and handling – Khamitov F.F., Matochkin E.A., Kuzubova E.A.; draft manuscript preparation – Khamitov F.F., Gergedava G.K., Gadzhimuradov R.U.; manuscript revision – Khamitov F.F., Gadzhimuradov R.U., Bobylev A.A., Shimanko A.I.
For citation: Khamitov F.F., Matochkin E.A., Gadzhimuradov R.U., Shimanko A.I., Bobylev A.A., Kuzubova E.A., Gergedava G.K. Surgical policy and peculiarities of management of patients with infection of an aortofemoral bifurcation synthetic prosthesis. Angiology and Vascular Surgery. Journal named after Academician A.V. Pokrovsky. 2024; 30 (2): 97–105. DOI: https://doi.org/10.33029/1027-6661-2024-30-2-97-105
Editor’s comment
The Editorial Council draws the reader’ attention to the fact that this work is a continuation of a multi-year study of surgical treatment of patients with suppuration of a synthetic bifurcation prosthesis in the aortoiliac position, analyzing the results of operations performed using the same technique.
Keywords: abdominal aortic aneurysm; Leriche syndrome; infection of synthetic prostheses; aortofemoral bifurcation prosthetic repair, autovenous redo prosthetic repair; femoral veins; sepsis
Introduction
The demand for open surgical and endovascular interventions on the abdominal aorta and its branches using synthetic vascular prostheses of various manufacturers (Ecoflon, Vascutek, Gore-Tex, Integrand, BASEKS, etc.) does not tend to decrease.
One of the most formidable problems of these operations both in the immediate and remote postoperative periods remains synthetic graft infection encountered according to the literature in 1 to 4% of cases [1-9]. Since the emergence of vascular surgery, there have always been attempts to explore different options and develop appropriate techniques of treating patients with suppuration of synthetic vascular prostheses: removal of a synthetic graft and atypical (extra-anatomical) subclavian-femoral bifurcation bypass with a synthetic prosthesis, aortofemoral bifurcation replacement by a synthetic prosthesis from the descending aorta through the obturator orifice. These operations were more often performed in two stages: stage 1 - removing an infected prosthesis and stage 2 - reconstructive operation [4, 10-14]. The main disadvantage of atypical operations include high frequency of reinfection amounting to 15-22%, unsatisfactory results of shunt patency in the immediate and especially remote postoperative periods, as well as division into stages, thus resulting in decompensation of blood circulation in the lower limbs and amputation in 20-27% of these patients. Postoperative mortality remained high amounting to 18-25% without a tendency to decrease [6, 7, 12, 14].
The last 10-15 years have seen a steadily growing number of supporters of in situ replacement using arterial homografts, synthetic prostheses impregnated with silver ions [6, 8, 9]. Advocates of this tactics report low frequency of prosthesis reinfection (4%) but high frequency of the development of false aneurysms of arterial homografts (8%) with postoperative mortality of not less than 4% within 30 days in the group with immunosuppressive therapy, to 15% - in the group of silver-coated synthetic prostheses. Moreover, high lethality was reported in the remote period due to development of such complications as homograft rupture (12%), thromboses and high amputations (12%), underlying that silver-coated prostheses could be as effective as arterialallografts in the treatment of infections of vascular prostheses.
Patients and methods
From 2001 to 2023, a total of 78 patients (72 men and 6 women) who underwent redo surgery on the aortofemoral segment at the Department of Vascular Surgery of the Municipal Clinical Hospital named after V.V. Veresaev. Of these, 76 patients had infection of aortofemoral bifurcation prostheses after open operations and 2 patients had infection after endoprosthetic repair. Prosthesis infection after primary operation in the immediate postoperative period was observed in 28 (35%) patients and in the remote period - in 50 (65%) patients, 3 of whom had previously been reoperated for prosthesis infection after primary operation. These 3 patients during re-operation received silver-coated vascular prostheses.
Primary operations of reconstruction of the aortoiliac zone were performed in 60 (77%) patients for Leriche syndrome, in 16 (20.5%) for aneurysms of the infrarenal aorta and iliac arteries, 2 (2.5%) patients underwent endoprosthetic repair of aneurysms of the infrarenal portion of the aorta. Thromboses of one of the branches of the prosthesis were revealed in 17 (21.8%) patients, secondary reconstructive operations (reconstruction of distal anastomosis, prosthetic-popliteal bypass grafting, crossover shunting due to branch thrombosis) were performed in 39 (50%) patients.
Comorbidity in all 78 patients was high, thus complicating the course of the postoperative period. The data of concomitant pathology are shown in Table 1.
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It was empirically noted that all synthetic prostheses made of polytetrafluoroethylene, according to own observations, as well as the findings of our colleagues, were infected only in the immediate postoperative period.
All patients suspected of having prosthesis infection underwent multislice computed tomography (MSCT) angiography, double bacteriological inoculation from the wound or purulent fistula, blood culture for microflora with determining sensitivity to antibiotics, blood analysis for determining markers of sepsis.
Depending on dissemination, we distinguish 3 types of synthetic prosthesis infection:
type 1 - local - infection of a distal anastomosis and branch below the Poupart’s ligament;
type 2 - subtotal - infection of a distal anastomosis and branch with the spread above the Poupart’s ligament but without involvement of a proximal anastomosis;
type 3 - total infection of a distal anastomosis and branch with involvement of the proximal anastomosis.
Of the analyzed 78 patients, 76 subjects after open aortofemoral reconstructions were found to have type 3 infection, with 2 patients diagnosed as having infection of the endoprosthesis.
While diagnosing synthetic graft infection, we were guided by the “golden” triad of signs, confirming this diagnosis:
1) a lingering fistula in the area of postoperative wounds with the presence of purulent discharge, and in some patients a branch of the vascular prosthesis can be visualized in the fistulous passage (see Fig. 4);
2) the presence of fluid in the paraprosthetic space by the findings of the ultrasound examination (USE) and MSCT angiography (see Fig. 12);
3) positive culture for microflora and an increase in markers of sepsis.
The data on the identified signs are shown in Table 2.
67 (86%) patients were found to have leukocytosis, 68 (87%) had anemia, elevated C-reactive protein (CRP), and 65 (83%) subjects had increased procalcitonin.
According to the findings of ultrasonography and MSCT angiography, air in the paraprosthetic space and paraprosthetic fluid were verified in all 78 (100%) patients. A pseudoaneurysm of the proximal or distal anastomosis was identified in 50 (65%) patients, aortoenteric fistulas were revealed in 8 (10%) cases, with thrombi on the prosthetic wall encountered rarely.
All patients prior to operation obligatorily underwent ultrasonographic duplex scanning (USDS) of the superficial and deep veins of lower extremities, as well as the internal jugular veins.
The microbiological study of paraprosthetic fluid and fistulous discharge from the area of distal anastomoses and wound demonstrated that the dominating causative agent both in the early and remote postoperative periods was MRSA (methicillin-resistant Staphylococcus aureus). The results of paraprosthetic contents inoculation are shown in Table 3.
All 78 patients after preoperative preparation underwent re-operation, consisted in removal of the synthetic aortofemoral bifurcation prosthesis in 76 patients and that of endoprosthesis in 2 patients, followed by aortofemoral bifurcation autovenous reconstruction in situ. The operation was performed by two teams of vascular surgeons. The first team performed the stage of exposure, harvesting and formation of an autovenous bifurcation prosthesis. The second team performed removal of the infected vascular prosthesis and the reconstructive stage of the operation.
The preoperative preparation was individual, depending on severity of hemostatic disorders, severity of intoxication, and the findings of the instrumental examination.
Stages of the operation and procedures performed.
Stage 1: exposure and harvesting of the femoral vein (FV) and proximal portion of the popliteal vein (PV) on both lower limbs from the ostium of the deep femoral vein (DFV) to the level of the knee joint cleft. The length of each harvested autovenous transplant averagely amounted to 28 - 33 cm (Fig. 1, 2).
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Stage 2: relaparotomy or laparotomy (if a retroperitoneal approach was used in the first operation), exposure of the proximal anastomosis (Fig. 3), followed by exposure of the distal anastomoses of the aortofemoral bifurcation bypass grafting on the femur (Fig. 4).
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Stage 3: formation of an autovenous bifurcation prosthesis from the reversed FVs (Fig. 5). To level out the difference in diameters with the abdominal aorta, we used a wedge-shaped insert into the main branch of the autograft, anastomosing two autoveins in a side-to-side manner. In case of insufficient length of the autovenous prosthesis, the internal jugular vein was used as the main branch, which was performed in 4 patients.
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Stage 4: removal of the infected prosthesis.
Stage 5: debridement of the bifurcation prosthesis bed was performed mechanically with compulsory chemical and ultrasonographic treatment.
Stage 6: formation of an end-to-end or end-to-side proximal anastomosis of the autovenous prosthesis with the aorta, with bringing the graft’s branches to the thighs and formation of distal anastomoses (Fig. 6-8).
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To demonstrate important aspects of the clinical course, diagnostic procedures, techniques of operation with the use of the femoral veins and internal jugular vein, we present the following case report.
Clinical case
Patient B., 58 years old, emergently admitted to the Municipal Clinical Hospital named after V.V. Veresaev on 08.02.2023 with complaints of general weakness, purulent discharge from wounds in inguinal areas, pain in both lower limbs, periodical increase in body temperature up to 39 °C with pronounced chills.
Anamnesis: on 07.12.2022 he underwent surgery for an aneurysm of the infrarenal aortic portion and iliac arteries at another vascular department of the city of Moscow. The scope of the first operation: resection of the aneurysm of abdominal aorta, iliac, common femoral arteries, aorto-deep-femoral bifurcation repair with a synthetic prosthesis. The postoperative period was complicated by lingering lymphorrhea from wounds on the thighs, formation of fistulas with purulent discharge. MSCT of the abdominal cavity and retroperitoneal space as of 24.01.2023 showed accumulation of fluid along the main and right branch of a bifurcation prosthesis (Fig. 9). The external view of the postoperative wounds on the thighs with purulent fistulas at admission is shown in Fig. 10.
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Conclusion: early total infection of a synthetic bifurcation prosthesis. Inoculation of discharge from wounds as of 25.01.2023: cultured was E. coli 104 CFU/ml, sensitive to amikacin, amoxicillin, levofloxacin (an indirect evidence of contamination from the gastrointestinal tract).
Anamnesis revealed that the patient had previously undergone phlebectomy on both lower extremities for varicose veins, as well as minor amputations of distal portions of both feet for diabetic foot syndrome. Stenting of the left common iliac artery as at 2013.
Concomitant diseases: type 2 diabetes mellitus, insulin-requiring. Nephropathy of mixed origin, stage IIIA chronic kidney disease. Arterial hypertension stage II, degree 2, risk of cardiovascular complications - stage IV, circulatory disorder - stage I-II according to NYHA.
Analyses: hemoglobin - 100 g/L; leukocytosis - 28.8 thou.; CRP - 236 mg/L, creatinine - 126.0 mcmol/L; PCT - 30.
Clinical diagnosis: early total infection of the aortofemoral bifurcation graft, on the right - occlusion of the superficial femoral artery (SFA), popliteal artery (PA), posterior tibial artery (PTA), on the left - occlusion of the SFA, thrombosis of a PA aneurysm, occlusion of the PTA. Stage IIb chronic lower limb ischemia.
Given the process of infection of the aortofemoral bifurcation prosthesis and a high risk for developing complications, a decision was implemented to perform an emergency operation for vital indications: removal of the infected bifurcation aortofemoral vascular prosthesis and autovenous bifurcation aorto-deep-femoral repair (the main branch of the prosthesis formed from the right internal jugular vein, prosthesis branches - from the femoral veins of both lower limbs).
Peculiarities of the operation: under combined anesthesia, using incisions on the thighs, femoral veins were harvested, each 35 cm long, then through the approach in the projection of the cervical nerve bundle on the right, the internal jugular vein was procured (Fig. 11). The wounds were sutured and drained. The harvested veins from the legs and the internal jugular vein were used to form a bifurcation autovenous prosthesis (Fig. 12).
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Distal anastomoses were exposed on the thighs, with distinct pulsation on the deep femoral artery (DFA) on both sides, both branches of the prosthesis coated with fibrin. Change of surgical instruments and linen. Complete midline laparotomy. Small amount of muddy exudate in the abdominal cavity. In the projection of the proximal anastomosis aortofemoral bifurcation prosthetic repair (AFBR) (at the level of renal arteries) pronounced inflammatory infiltration of tissues, the adjacent to infiltrate jejunum with dull serosa, coated with fibrin. The abdominal aorta exposed above the renal arteries [systemic heparinization (5 thou. U)], an aortic clamp placed above the renal arteries, the infected vascular prosthesis (AFBR) resected and removed (Fig. 13). In the area of the proximal anastomosis, a para-aortic abscess was opened, containing up to 150 ml of pus with pungent odor, sent for bacteriological examination. The lumbar arteries and distal end of the aorta sutured through. An end-to-end proximal anastomosis between the aorta and autovenous bifurcation prosthesis was created at the level of renal arteries using Prolene 5/0 thread. The duration of aortic clamp and renal ischemia amounted to 25 minutes. The branches of the autovenous prosthesis retroperitoneally brought out to the thighs and anastomosed the DFA in an end-to-end manner on both sides. Restoration of blood flow. Pulsation on the autovenous prosthesis and DFA on the right and left distinct. The view of the postoperative wound after blood flow restoration through the autovenous bifurcation prosthesis is shown in Fig. 14. Drainage of the left mesenteric sinus (drain through a counter-aperture was brought out in the left iliac region), drainage of the small pelvis through a counter-aperture in the right iliac region). Layer-by-layer suturing of the laparotomic wound. The branches of the autovenous prosthesis on the thighs from both sides were covered by the sartorius muscle, with sutures on the femoral wounds, aseptic dressing applied. The view of the postoperative wounds is shown in Fig. 15.
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In the early postoperative period, it was required to perform 3 sessions of ultrahemodiafiltration, followed by stimulation of intestinal function, antibacterial, anticoagulation therapy, adequate pain relief. On POD 5, the patient in a stable condition was transferred to the Vascular Surgery Department. Laboratory parameters: hemoglobin - 96 g/L, RBC - 4.2; Ht - 34.2%; WBC - 8.3 (maximal elevation to 36.0x109/L as of 11.02.23 in the early postoperative period); CRP - 123 (as of 13.02.2023 - 236.67); PCT - 3. There was no need to apply VAC-system and make additional measures on evacuation of the infected content, with the drains removed on day 3. The wounds on the thighs were dressed using ointments based on silver ions (Argosulfan, Vascopran with dioxydin). On POD 6, the patient was activated, with a compression bandage applied. The wounds healed with (first) primary intention. The patient was discharged on POD 11 in a satisfactory condition. On 07.022023 he underwent control MSCT angiography (Fig. 6), showing good patency of the autovenous prosthesis, with no evidence of paraprosthetic inflammation, no retroperitoneal formations or false aneurysms. Outpatient examination on 15.05.2023 demonstrated complete wound healing. At 3 months after surgery, good patency of the autovenous prosthesis was noted.
Results
Twelve (15%) patients died in the early postoperative period. The main causes of lethal outcomes were septic shock in 8 (10%) cases and myocardial infarction in 2 (2.5%) cases on POD 12 and 15. Postoperative complications in the immediate postoperative period are shown in Table 4.
Arrosive bleeding developed in 4 patients, with the source being defects of autovenous implants into the retroperitoneal space and/or abdominal cavity. This complication developed on POD 2 - 5. All these patients were diagnosed with sepsis and were operated on in the immediate postoperative period after the primary operation. We managed to save the life of only 1 of them. The remote results up to 14 months were analyzed in 51 (65%) patients. Of these, prosthesis patency was preserved in 46 (90%) patients, which was confirmed by the findings of USDS and control MSCT angiography. An MSCT angiogram 5 years after reconstruction for suppuration of a bifurcation prosthesis is shown in Fig. 17.
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Only one patient 2 years after surgery developed false aneurysms of distal anastomoses, which were operated on successfully.
Discussion
Infection of aortofemoral bifurcation allografts is one of the most formidable complications and is accompanied by high mortality. Verification of tis complication at the present level of medicine does not cause much difficulty. Based on such methods as USDS, MSCT angiography, results of bacteriological cultures from the wound, blood it is possible to rapidly and accurately make a diagnosis and to determine the causative agent. Currently, there is no alternative to surgical treatment of patients with this complication.
One of the most important questions in these patients is that of the choice of the material for repeat prosthetic repair. Various authors as a variant for replacement of an infected prosthesis propose homografts in complex with immunosuppressive therapy, autografts from femoral arteries and even synthetic prostheses impregnated with silver ions. We abandoned repeat application of synthetic prostheses impregnated with silver ions based on own negative experience: we had carried out treatment of 2 patients after re-operations with implantation of synthetic prostheses and in both cases after a short time (1.5 and 4 months, respectively) we ascertained the development of a paraprosthetic phlegmon followed by recurrent arrosive bleeding. We had operated those patients as an emergency in the scope of autovenous aortofemoral reconstruction with a good clinical result.
Xenopericardial prostheses are also used in clinical practice. We have no own experience, but the authors using this tactics report formation of false aneurysms and rupture of xenopericardial prostheses.
With an increase in the frequency of publications, reports, scientific articles, clinical observations there gradually increases the number of vascular surgeons proposing surgical intervention in the scope of simultaneous removal of infected prostheses and autovenous replacement in situ as a method of choice with good remote results [6-9].
Our study demonstrated that in suppuration of a bifurcation synthetic graft in the aortoiliac position, the use of an autovenous transplant for replacement should be recognized as an optimal option, since this type of transplant is autologous for the patient, is distinguished by an adequate diameter and required length, and most importantly it is highly resistant to infection and possesses low thrombogenicity. Besides, long-term studies with a follow-up of 5 years and more demonstrated good durability of this transplant. It is precisely thanks to the aggregate of all these advantageous properties of an autovenous transplant that its use in infection of a synthetic vascular graft is more justified than the use of other suggested materials [3, 5-9, 13, 15].
Conclusion
In suppuration of a bifurcation aortofemoral prosthesis, an active surgical policy consisting in removal of an infected bifurcation synthetic prosthesis with replacement by a graft from autoveins makes it possible to attain satisfactory outcomes in the immediate postoperative period and good long-term results.
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