Post-operative transfusion is associated with infrainguinal bypass graft failure: contemporary Australian tertiary centre experience.

BACKGROUNDS: Peripheral arterial disease (PAD) is an increasingly prevalent and highly morbid pathology affecting the older population. Infra-inguinal bypass (IIB) surgery remains a robust revascularization option in these patients. This study aimed to identify modifiable predictors associated with graft patency and functional outcomes in contemporary Australian vascular surgical practice. METHODS: A retrospective analysis of patients undergoing IIB between 2010 and 2020 at a tertiary vascular surgery centre in Australia was performed. Data regarding patient demographics, co-morbidities, pre-operative investigations, bypass characteristics, and discharge outcomes were collected. Surveillance ultrasound scans were reviewed to gain information on graft patency and compliance up to 2 years post-operatively. The primary outcome was graft failure. Secondary outcomes were mobility status and amputation-free survival at 1 year. RESULTS: A total of 239 IIBs were performed on 207 patients during the 10-year period. Significant predictors for primary graft occlusion included regional referral (P < 0.01), low pre-operative haemoglobin level (P < 0.01), post-operative transfusion requirement (P = 0.02), use of prosthetic conduit (P < 0.01) and non-compliance to ultrasound surveillance (P < 0.01). Patients with a thrombosed graft were 2.4 times more likely to experience deterioration in mobility status (P < 0.01) and 8.6 times more likely to have major limb amputation or death at 1 year. The amputation-free survival was 88.3% at 1 year. CONCLUSION: Optimization of pre-operative haemoglobin level for IIB should be advocated in clinical practice in order to reduce the risk of graft failure, deterioration in ambulatory function, major limb amputation and mortality.

Complex Hybrid Repair of a Secondary Aortoenteric Fistula.

Background: Secondary aortoenteric fistula is a rare, highly morbid and often difficult to diagnose, cause of gastrointestinal bleeding. It is associated with prior aortic surgery or placement of a synthetic aortic graft. Our case features staged hybrid endovascular stent-grafting, graft excision, aortoplasty using a bovine pericardial patch, extra-anatomical bypass and complex bowel repair. Case Report: An 82-year-old man presented with gastrointestinal bleeding and Streptococcus Anginosus bacteraemia, with previous aorto-bi-iliac bypass surgery for left common iliac occlusive disease 15 years ago. Computed tomography angiography (CTA), gastroscopy, colonoscopy, capsule endoscopy and enteroscopy identified no bleeding source. Repeat CTA showed gas locules and stranding around the graft and the third part of the duodenum, concerning for fistulous communication. On the next day, a Zenith TX2 thoracic 28x80mm stent-graft was deployed into the infrarenal aorta. On laparotomy, a fistula was present between the Dacron graft and fourth part of the duodenum. The Dacron graft was excised, followed by aortic patching with bovine pericardium. A right-to-left femoral-femoral crossover graft was constructed. CT at one-month post-laparotomy showed no signs of perigraft endoleak and interval resolution of gas locules. He was transferred to a rehabilitation facility on the 34th post-operative day with a multidisciplinary follow-up arranged. Discussion: Aortoduodenal fistula is a challenging entity to diagnose and should be suspected in patients with GI bleeding and prior aortic surgery. Endovascular repair alone is a less invasive option but with higher re-infection and late failure rates. Liberal use of appropriate imaging modalities, a judicious repair strategy, long-term follow-up and multidisciplinary approach are critical for its management.