The Role of Antigranulocyte Scintigraphy in Diagnosis of Aortic Graft Infection and Evaluation of Treatment Outcome.

BACKGROUND: The aim of this study was to assess the eventual added benefit of antigranulocyte monoclonal antibodies scintigraphy for the diagnostic imaging of aortic graft infection (AGI) and its role in evaluation of treatment outcome. METHODS: A population-based, retrospective, register-based analysis was carried out of all patients with infected aortic grafts after treatment for aneurysmal or aortoiliac occlusive disease at Karolinska University Hospital, covering the greater Stockholm area during November 2012-December 2020. Cases were based on the definitions in the 2016 Management of Aortic Graft Infection Collaborations consensus. Using the in-hospital electronic patient registry (Take Care®) and the Swedish National Registry for Vascular Surgery (Swedvasc), 835 patients who had been treated for aortic aneurysms or aortoiliac occlusive disease were identified. The diagnostic arsenal of laboratory tests, computed tomography (CT), and clinical signs has been supplemented by antigranulocyte monoclonal antibodies (anti-G mAb) scintigraphy. Data were analyzed using SPSS Statistics. RESULTS: Eighteen cases of AGI out of 835 operations incorporating aortic grafts during the period were identified. Fourteen patients (78%) were categorized as diagnosed AGI (AGI-D), and the remaining 4 (22%) were classified as suspected AGI (AGI-S). In the AGI-D group (n = 14), 10 patients (71%) had positive CTs and 4 (29%) had low-probability CTs. In the group of 10 positive CTs, 9 patients also had positive scintigraphy scans with only one negative scintigraphy scan. There were no negative scintigraphy scans without ongoing antibiotic treatment at the time of investigation. In 15 of 18 cases, a culprit agent was identified, either preoperatively or perioperatively. Thirteen of the 18 patients were treated solely by antibiotics, whereas 5 underwent surgical treatment in addition to antibiotic treatment. The outcome has been divided into 3 groups: infection-free (n = 6; 33%), lifelong antibiotic treatment (n = 7; 39%), and deceased (n = 5; 28%). CONCLUSIONS: The imaging modalities in AGI diagnostics are a cornerstone of the investigative work-up, complemented by clinical signs and laboratory methods. The main advantage conveyed by anti-G mAb scintigraphy is in postoperative imaging and its ability to differentiate between infection and general postoperative changes in the areas of concern. We have identified 6 patients in our cohort in whom antibiotic therapy was discontinued after a negative anti-G mAb scintigraphy scan. Anti-G mAb scintigraphy may fulfill a unique need for diagnosis in suspected cases, evaluation of therapeutic efficacy in patients requiring long-term antibiotic treatment, and aiding in the decision to discontinue antibiotic therapy.

Novel method for direct retransfusion reduces blood transfusions in descending and thoracoabdominal aneurysm repair.

BACKGROUND: Allogenic blood product usage is associated with worse outcomes in open repair of descending and thoracoabdominal aortic aneurysms. This pilot study evaluated the safety and efficacy of a novel modification of the left heart bypass (LHB) circuit to reduce intraoperative blood transfusions. METHODS: In modified LHB, pump suckers collected shed blood that was directly retransfused through a femoral vein cannula. In standard LHB, cellsavers were used to collect, wash, and retransfuse shed blood. Consecutive patients undergoing elective surgical descending or thoracoabdominal aneurysm repair using modified (N.=12) or standard (N.=21) LHB were compared. Intraoperative blood product use was the primary outcome. Hypotensive episodes, lactate levels, and adverse events (early mortality, spinal cord injury, renal and respiratory insufficiency) were secondary outcomes. RESULTS: Groups were comparable regarding pre- and intraoperative variables. No perfusion-related adverse events occurred. With modified LHB, intraoperative blood product use was significantly reduced: packed red blood cells by 60% from 10 to 4 units (P=0.002), fresh frozen plasma by 70% from 17 to 5 units (P<0.001) as well as retransfused cellsaver volume by 75%, from 4500 mL to 1110 mL (P<0.001). Hemodynamic instability occurred in 1 (8.3%) vs. 6 (29%), P=0.22 and overall lactate levels were significantly reduced (P=0.045) with modified LHB. Adverse events combined occurred in 1/12 vs. (P=0.022). CONCLUSIONS: The novel modified LHB with direct retransfusion was safe and associated with significantly reduced intraoperative blood product use, reduced lactate production and improved clinical outcomes as compared to standard LHB and could represent an important clinical improvement.

Outcomes of descending and thoracoabdominal aortic repair in connective tissue disorder patients.

OBJECTIVES: Open surgical repair (OSR) of descending and thoracoabdominal aortic aneurysms carries risks of mortality and major complications. Patients with connective tissue disorders (CTD) are younger and require safe, efficient treatment with long-term durability. This study provides current outcome data to help inform treatment decisions. METHODS: All OSRs of descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) from January 2011 to July 2021 were included in a retrospective cohort study. Primary outcome measures were early and follow-up mortality and reintervention. Secondary outcome measures were major complications. Kaplan-Meier methods were used to estimate reintervention-free survival. RESULTS: A total of 26 OSRs (7 DTAA, 19 TAAA) were performed in 23 patients: 20 (77%) Marfan and 6 (23%) Loeys-Dietz syndrome; median age 43 years. Aortic dissection was present in 100% and 3/26 (12%) were urgent. Early mortality was 1/26 (3.8%). No patient suffered spinal cord ischemia, stroke, vocal cord paralysis, or re-exploration for bleeding. The transient respiratory failure occurred in 19% (5/26) and transient renal replacement therapy in 15% (4/26). Renal function normalized in all patients within 3 months. During follow-up (median 4.6, range 0-11 years) there were no deaths and only one re-intervention on a previously operated aortic segment, resulting in 92% reintervention-free survival at 5 years. CONCLUSIONS: In dedicated units, open surgical DTAA and TAAA repair in patients with CTD can be performed with a very low risk of death, severe complications and, late re-intervention. For CTD patients with reasonable risk, OSR should remain the first line of treatment.

Deep Femoral Vein Reconstruction for Abdominal Aortic Graft Infections is Associated with Low Aneurysm Related Mortality and a High Rate of Permanent Discontinuation of Antimicrobial Treatment.

OBJECTIVE: Aortic prosthesis infection is a devastating complication of aortic surgery. In situ reconstruction with the neo-aorto-iliac system (NAIS) bypass technique has become increasingly used and is recommended in recent treatment guidelines. The main aim was to evaluate NAIS procedural outcomes when undertaken after previous open or endovascular aortic repair in Sweden. METHODS: In this retrospective study, The National Quality Registry for Vascular Surgery (Swedvasc) was used to identify Swedish centres that offered the NAIS bypass procedure for aortic prosthesis infection between 2008 and 2018. Variables of special interest were procedural details, short and long term survival, renal and other complications, and the durtion of antimicrobial treatment. RESULTS: Forty patients (36 males, four females [mean age 69 years], 32 open repairs, seven endovascular aortic repairs [EVAR] and one fenestrated EVAR; 21 presented with aorto-enteric fistula) operated on with NAIS bypass were reviewed. The median time from the primary aortic intervention to the NAIS bypass procedure was 32 months (range 0 - 252 months). Mean ± standard deviation operating time was 645 ± 160 minutes, mean blood loss was 6 277 ± 6 525 mL, mean length of intensive care unit stay was 5.3 ± 3.7 days, and mean length of overall hospital stay was 21.2 ± 11.4 days. Thirty-five patients (88%) had a positive microbial culture; the most commonly isolated pathogen was Candida spp. The majority of patients survived for 30 days (n = 35 [88%]), and 33 (83%) and 32 (80%) patients survived for 90 days and one year, respectively. The number of surviving patients free from antimicrobial treatment at 90 days, six months, and one year was 19 (58%), 29 (88%), and 30 (94%). After a mean long term follow up of 69.9 ± 44.7 months, 20 patients were still alive. CONCLUSION: The NAIS bypass procedure offered reasonable survival and functional outcomes, and was associated with a high cure rate, defined as freedom from any antimicrobial treatment.

Iliaco-enteric fistula after robot-assisted comprehensive surgical staging of endometrial cancer: a case report.

Fistula formation between bowel and blood-vessel is a very rare complication after intraabdominal surgery. We report a case of iliaco-enteric fistula following robot-assisted surgical staging of endometrial cancer. A 71-year-old woman subjected to comprehensive endometrial cancer staging presented with hematochezia 35 days postoperatively. A retroperitoneal right-sided abscess and an iliaco-enteric fistula was confirmed upon imaging. The patient received endovascular repair of the aneurysm in her right common iliac artery and the segments of the small bowel containing the fistula were resected via laparotomy. If a patient presents with new onset postoperative hematochezia after pelvic and/or paraaortic lymphadenectomy, fistulation between bowel and the major abdominal blood vessels should be part of the differential diagnoses.

Aortic Graft Infections after Emergency and Non-Emergency Reconstruction: Incidence, Treatment, and Long-Term Outcome.

BACKGROUND: Aortic graft infections (AGI) are rare, with an incidence of 0.6%-3% among patients with aortic grafts. Most previous reports are based on single-center material with limited follow-up. Because of the paucity of these cases, the optimal treatment remains unclear. A factor possibly affecting the mortality rate of these infections is whether the index procedure was emergency or elective. The aim of this study was to investigate the incidence of AGI and assess the long-term outcome after emergency and non-emergency aortic reconstruction in a large population. METHOD: A population-based, retrospective study was conducted of all patients treated with aortic reconstructive surgery at the two centers for vascular surgery in Stockholm County (population 2.2 million) during 2005-2015. Patients with AGI were identified by the in-hospital patient registry. Chart data on demographics, co-morbidity, index operation, type of infection, treatment, and outcome were analyzed. RESULTS: Reconstructive aortic surgery was performed on 2,026 patients (open repair 47.7%; endovascular aortic repair 52.3%). The incidence of infection was 1.4% (29/2,026). The index operation was performed as an emergency in ten patients and non-emergency in 19. Median follow-up after the index operation was 69.2 months (interquartile range [IQR] 109.5). Patients having an emergency index procedure were older (77 vs. 69 y; p = 0.03). Time to infection was similar (30.2 ± 27.4 and 56.1 ± 51.2 mos; p = 0.21). The median time from diagnosis of AGI to surgery was 30 d (IQR 30.5 d). Infectious agents were identified in 76% of the cases. Of the conservatively treated patients, one was free of infection compared with three of the surgically treated. Conservatively treated patients had a higher graft-associated mortality rate of 57% compared with 25% of the surgically treated (p = 0.05). CONCLUSIONS: This population-based study with long-term follow-up confirms the low incidence of AGI, 1.4%. The similar incidence in the emergency and non-emergency groups suggests that the index operation is not decisive in the development of AGI. The outcome of these infections generally is poor but is worse for non-surgically treated patients.

Perioperative cytokine response to infection associated with elective arterial surgery.

OBJECTIVE: The aim was to assess the cytokine response to acute inflammation and infection in vascular surgery. DESIGN OF STUDY: Single-center, prospective cohort study. METHODS: Blood samples from 96 consecutive patients undergoing elective vascular surgery were analyzed for C-reactive protein (CRP), total leukocyte counts (LPK), neutrophil CD64 expression, and cytokines using enzyme-linked immunosorbent assay. RESULTS: Of the 25 investigated cytokines, 22 had lower postoperative mean values compared to preoperative values. Interleukin (IL) 6 (IL-6) was the only cytokine that increased significantly postoperatively. Combined analysis of CRP and CD64 together with IL-6 or IL-10 showed an individually unique association with postoperative infection (P < .05). CONCLUSION: We have shown a positive correlation with perioperative infection for the proinflammatory cytokines and the anti-inflammatory cytokine IL-10 as well as a number of chemokines. To our knowledge, this is the first report linking IL-10 and chemokine plasma levels to perioperative infection in vascular surgery.

Novel Visceral-Anastomosis-First Approach in Open Repair of a Ruptured Type 2 Thoracoabdominal Aortic Aneurysm: Causes behind a Mortal Outcome.

Case reports to analyze causes and possible prevention of complications in a new setting are important. We present an open repair of a ruptured type 2 thoracoabdominal aortic aneurysm in a 78-year-old man. Lower-body perfusion through a temporary extracorporeal axillobifemoral arterial prosthesis shunt was combined with the use of a branch to the permanent aortic prosthesis to enable rapid visceral revascularization using a visceral-anastomosis-first approach. The patient died due to transfusion-induced capillary leak syndrome and left colon necrosis; the latter was probably caused by a combination of back-bleeding from lumbar arteries causing a steal effect, an accidental shunt obstruction, and hemodynamic instability towards the end of the operation. The visceral-anastomosis-first approach did not contribute to the complications. This approach reduces the time when visceral organs are perfused only via collateral arteries to the time needed for suturing the visceral anastomoses. This may be important when collateral perfusion is marginal.

Treatment of a hepatic artery aneurysm by endovascular stent-grafting.

Aneurysms of the visceral arteries are rare. Traditional treatment has been surgical or endovascular with coil embolization. Recently, however, reports on endovascular therapy with stent-grafts have been published. We report the case of a 61-year-old man who was successfully treated with a stent-graft for a symptomatic combined celiac/hepatic artery aneurysm.

Complications associated with the Angio-Seal arterial puncture closing device: intra-arterial deployment and occlusion by dissected plaque.

The Angio-Seal arterial closure device is widely used to prevent bleeding and facilitate early ambulation after arterial puncture. We had referred to us three female patients in whom this device had been used; its sponge had been unintentionally deployed in the arterial lumen. In a fourth female patient, a dissected plaque underneath the device occluded the femoral artery. Severe lower extremity ischemia occurred in each case. One intraluminal sponge was detected only after 20 days, when the patient had developed severe symptoms due to microembolization; in another patient, ischemia occurred 9 days after intraluminal deployment. In two, or possibly three, of the cases, the superficial femoral artery had been punctured. The device should not be used when the superficial femoral artery has been punctured, in which case complications are more likely to occur. Lower limb ischemia within several months after deployment of these devices should be investigated with duplex ultrasound scanning to examine the possibility that the ischemia may be caused by the device or by device-related thrombus. It is important to register the use of such devices in the procedural reports to make it possible to link their use to eventual later ischemic events.