Successful Treatment of Prosthetic Graft Infection 7 Years after Ascending Aorta Replacement and Aortic Root Replacement with a Freestyle Stentless Valve / 日本心臓血管外科学会雑誌

A 62 year-old man presented with severe septic shock complicated by prosthetic graft infection, 7 years after aortic root replacement with a Freestyle stentless valve and graft replacement of the ascending aorta. We initially managed the patient with antimicrobial therapy for 2 months and subsequently surgery was performed, replacing the infected aortic graft with rifampicin-bonded prostheses, and added omentopexy. The infection was cured and has not recurred.

A Case of Vascular Graft Infection by <i>Aspergillus </i>Causing Distal Embolism to the Foot / 日本心臓血管外科学会雑誌

A 77-year-old woman with previous aortic grafting for abdominal aortic and iliac artery aneurysms developed a blue toe in her left foot. Enhanced CT showed a high density area around the vascular graft of the left iliac artery, which partially protruded into the graft. Because of the elevated <i>β</i>-D glucan level, fungal infection of the vascular graft was strongly suspected. Her general condition precluded the graft removal. Instead, thrombectomy was performed. Microbial examination of the removed clot revealed infection by <i>Aspergillus fumigatus</i>. Voriconazole was administered for 3 months. The <i>β</i>-D glucan level was normalized. Only thrombectomy and Voriconazole administration can be an alternative in case with vascular graft infection by <i>Aspergillus</i>.

Anterior Small Thoracotomy Drainage and Intermittent Lavage in 2 Cases of Prosthetic Graft Infection after Arch Replacement Surgery / 日本心臓血管外科学会雑誌

Prosthetic graft infection after arch replacement surgery is a serious complication that is often resistant to antibiotics. However, graft replacement is difficult and is very invasive. We performed anterior small thoracotomy drainage and intermittent lavage in 2 patients. First, the prosthetic graft was approached via a left third intercostal thoracotomy. After the ablation of infected tissues and cleansing with saline, drains were placed both proximally and distally to the vascular graft. An irrigation withdrawal drain was then implanted in the left thoracic cavity. After surgery, diluted povidone iodine solution, pyoktanin solution, and saline were used for pleural lavage. Case 1 : An 82-year-old man underwent arch replacement for a ruptured aortic arch aneurysm in November 2005. He suffered from high-grade fever from March 2008 and was referred to our hospital from another hospital with a diagnosis of vascular graft infection. A small anterior thoracotomy and drainage were performed on April 9. Pleural lavage with povidone iodine solution was performed 9 days after surgery, then was performed with saline from days 10-13 after surgery. The patient was discharged on postoperative day 30. Case 2 : A 58-year-old man complained of high-grade fever from March 16, 2009. He had undergone arch replacement for an aortic arch aneurysm in 1997. He consulted a physician and was referred to our hospital with a diagnosis of vascular graft infection. Methicillin-sensitive <i>Staphylococcus aureus</i> (MSSA) was identified by blood culture. A small anterior thoracotomy and drainage were performed on March 24. Immediately after surgery pleural lavage was performed with pyoktanin blue solution changing to povidone iodine on postoperative day 10. Pleural lavage was continued until day 34, and the patient was discharged on postoperative day 64. In both cases, drainage and pleural lavage with antibiotic solutions improved the patients' general condition. The infections have not recurred since discharge. Small anterior thoracotomy for graft infection after arch replacement, in addition to being minimally invasive, can avoid the need for a second median sternotomy, and can provide an adequate view of the full length of the arch prosthetic graft.

FDG Uptake Pattern of a Prosthetic Graft without Infection on a PET/CT Scan

PURPOSE: A prosthetic graft infection is a rare but often disastrous complication during vascular surgery. Diagnosis of a prosthetic graft infection is not always easy, particularly with a low virulent bacterial infection or in a deeply placed graft in the retroperitoneal space. Recently, fludeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) has been proposed as a diagnostic modality for prosthetic graft infection. However, some reports have indicated that high FDG uptake occur in grafts without infections. This study analyzed FDG uptake patterns in prosthetic grafts of asymptomatic patients. METHODS: We reviewed 14,545 patients who had received PET/CT in a tertiary hospital between July 2007 and March 2010. Of them, 11 patients who had undergone previous bypass surgery with a prosthetic graft were identified. Four underwent an aortic bypass and the others received lower extremity bypass grafting. PET/CT images and patient clinical data were reviewed retrospectively. The maximum standardized uptake value (SUVmax, A) in the graft, the mean SUV (SUVmean, B) of the blood-pool, and the target-to-background ratio (T/B, A/B) were calculated. RESULTS: The mean duration between bypass grafting and the PET/CT scan was 21 months (range, 1~80 months). No clinical evidence of graft infection was observed in any of the patients. PET/CT revealed an uneven, diffuse FDG uptake pattern on the grafts, and the mean T/B was 2.0 (range, 0.9~4.6). T/B was greater than 2.0 in six patients (55%). CONCLUSION: A prosthetic graft without an infection can result in increased FDG uptake during PET/CT. A further prospective study is necessary to evaluate the usefulness of FDG PET/CT for diagnosing a prosthetic graft infection.

Experience with Transobturator Foramen Bypass Surgery: a Case Report

The obturator bypass operation is not a common procedure. In 1963, Shaw and Baue first described performing bypass surgery through the obturator foramen as a technique to deal with infected arterial prostheses in the groin. This operation has been used to reconstruct patients with groin infection, irradiation ulcer, mycotic aneurysm, trauma and excessive scar tissue in the femoral region. We experienced one case of transobturator foramen bypass surgery from a Dacron iliac limb to the popliteal artery.

A Case of Aorto-femoral bypass Graft Infection Complicated with Infective Endocarditis / 감염과화학요법

Prosthetic vascular graft infection (PVGI) is a relatively uncommon complication of peripheral vascular surgery and although rare, is the most severe complication in reconstructive vascular surgery. The early diagnosis of this complication can reduce the mortality. We report a case of aorto-femoral bypass graft infection, which was diagnosed by Tc-99m HMPAO WBC scan, complicated with infective endocarditis. A 60-year-old man had been operated with aortofemoral bypass graft because of aortojejunal fistula due to abdominal aortic aneurysm. Nine months later, he was admitted with fever of two months' duration. On echocardiolography, aortic regurgitation and vegetation were observed, and then he was diagosed with infective endocarditis. He was treated with antibiotics for 6 weeks. Recurrent bacteremia of unknown origin persisted despite antibiotic therapy. Multiple microorganisms were separately isolated from the blood cultures. He complained of intermittent right groin pain. Imaging study (CT, MRI, US) showed no definite evidence of graft infection. However, Tc-99m HMPAO WBC scan demonstrated uptake in the aortofemoral bypass graft site. The patient underwent emergent aortofemoral graft removal with axillobifemoral bypass and right femoropopliteal bypass.

A Case of Aorto-femoral bypass Graft Infection Complicated with Infective Endocarditis / 감염과화학요법

Prosthetic vascular graft infection (PVGI) is a relatively uncommon complication of peripheral vascular surgery and although rare, is the most severe complication in reconstructive vascular surgery. The early diagnosis of this complication can reduce the mortality. We report a case of aorto-femoral bypass graft infection, which was diagnosed by Tc-99m HMPAO WBC scan, complicated with infective endocarditis. A 60-year-old man had been operated with aortofemoral bypass graft because of aortojejunal fistula due to abdominal aortic aneurysm. Nine months later, he was admitted with fever of two months' duration. On echocardiolography, aortic regurgitation and vegetation were observed, and then he was diagosed with infective endocarditis. He was treated with antibiotics for 6 weeks. Recurrent bacteremia of unknown origin persisted despite antibiotic therapy. Multiple microorganisms were separately isolated from the blood cultures. He complained of intermittent right groin pain. Imaging study (CT, MRI, US) showed no definite evidence of graft infection. However, Tc-99m HMPAO WBC scan demonstrated uptake in the aortofemoral bypass graft site. The patient underwent emergent aortofemoral graft removal with axillobifemoral bypass and right femoropopliteal bypass.