In situ rifampin-soaked grafts with omental coverage and antibiotic suppression are durable with low reinfection rates in patients with aortic graft enteric.

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Presentation transcript:

In situ rifampin-soaked grafts with omental coverage and antibiotic suppression are durable with low reinfection rates in patients with aortic graft enteric erosion or fistula Gustavo S. Oderich, MD, Thomas C. Bower, MD, Jan Hofer, RN, Manju Kalra, MBBS, Audra A. Duncan, MD, John W. Wilson, MD, Stephan Cha, MS, Peter Gloviczki, MD Journal of Vascular Surgery Volume 53, Issue 1, Pages 99-107.e7 (January 2011) DOI: 10.1016/j.jvs.2010.08.018 Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 1 Technique of in situ rifampin-soaked graft (ISRG) replacement for aortic graft enteric erosion. A, The aorta is clamped below the renal arteries and the infected graft is excised with preservation of well-incorporated portions of the iliac limbs. A small rim of fabric is left adhered to the duodenum. B, After debridement and irrigation, the aortic graft is replaced with ISRG, and the tongue of the omentum is brought through the mesocolon. C, The omentum is wrapped circumferentially around the ISRG. D, The inset shows repair of the duodenal erosion with primary anastomosis. Journal of Vascular Surgery 2011 53, 99-107.e7DOI: (10.1016/j.jvs.2010.08.018) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 2 (online only) A 60-year-old male with prior endovascular repair of infrarenal abdominal aortic aneurysm presented with fever, leukocytosis, and abdominal pain. A, A computed tomography angiography revealed air in the aneurysm sac, lack of fat plane between the duodenum and aneurysm sac, and large left psoas muscle abscess. After percutaneous drainage of the abscess cavity, the endograft was explanted (B) and the aorta was replaced in situ using femoropopliteal vein graft (C and D). Journal of Vascular Surgery 2011 53, 99-107.e7DOI: (10.1016/j.jvs.2010.08.018) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 3 (online only) A, A 68-year-old male treated for aortic graft enteric fistula with an in situ rifampin-soaked graft. B, Portion of the infected graft and aortic wall were left attached to the duodenal defect, showing the anastomotic line involved by fistula. C, The illustration depicts a “fishmouth” anastomosis, which was used in patients with supra-graft aneurysms or anastomosis close to the renal arteries. D, Follow-up computed tomography angiography revealed a well-incorporated main graft body and iliac limbs without evidence of reinfection. Journal of Vascular Surgery 2011 53, 99-107.e7DOI: (10.1016/j.jvs.2010.08.018) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 4 (online only) Computed tomography of the abdomen and intraoperative photographs in 3 patients with aortic graft enteric erosion or fistulas. Findings included evidence of a portion of the graft within the lumen of the jejunum (small arrow) as shown in a patient with prior stenting of the graft limb (A); note the well-incorporated main graft body (curved arrow). Other findings included lack of fat plane between the graft and bowel and/or presence of perigraft air and fluid (B, small arrow) and supra-graft para-anastomotic aneurysm (C, arrowhead) associated with lack of fat plane between the graft and bowel in a patient with aortic graft fistula with involvement of the anastomotic suture line (C, long arrow). Journal of Vascular Surgery 2011 53, 99-107.e7DOI: (10.1016/j.jvs.2010.08.018) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 5 Kaplan-Meier survival estimates in 54 patients treated for aortic graft enteric erosion or fistula (AGEF) with in situ rifampin-soaked grafts and comparison to survival of age-matched and gender-matched controls from the Minnesota (MN) population. Journal of Vascular Surgery 2011 53, 99-107.e7DOI: (10.1016/j.jvs.2010.08.018) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 6 Kaplan-Meier estimates for freedom from graft re-infection in 54 patients treated for aortic graft enteric erosion or fistula (AGEF) with in situ rifampin-soaked grafts. Journal of Vascular Surgery 2011 53, 99-107.e7DOI: (10.1016/j.jvs.2010.08.018) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 7 (online only). Kaplan-Meier estimates for freedom from graft-related complications in 54 patients treated for aortic graft enteric erosion or fistula (AGEF) with in situ rifampin-soaked grafts. The dotted line represents an SD > 10%. Journal of Vascular Surgery 2011 53, 99-107.e7DOI: (10.1016/j.jvs.2010.08.018) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 8 (online only). Kaplan-Meier estimates for primary graft patency in 54 patients treated for aortic graft enteric erosion or fistula (AGEF) with in situ rifampin-soaked grafts. Journal of Vascular Surgery 2011 53, 99-107.e7DOI: (10.1016/j.jvs.2010.08.018) Copyright © 2011 Society for Vascular Surgery Terms and Conditions