Fryderyk Pukacki

Current options in prosthetic vascular graft infection: comparative analysis of 63 consecutive cases

PurposeThe study was conducted to compare the results of two different techniques of vascular reconstruction in patients after the removal of infected vascular prostheses.MethodsSixty-three patients with vascular prostheses infections underwent treatment. Either the infected fragments or the entire prosthesis was removed in all of the patients. Extra-anatomical grafts were implanted in 19 cases. Cryopreserved allogenic arterial grafts were applied for reconstruction in 44 patients.ResultsIn a 19-patient group with extra-anatomical grafts, two patients died (10.5%). In seven patients (36.8%) relapse symptoms of infection appeared. Primary and secondary patencies of the grafts after 3 years were 31.6% and 52.6% respectively. In a group of 44 patients with allogenic grafts no recurrence of infection was observed. Six patients died (13.6%). Primary and secondary patencies after 3 years were 63.6% and 81.8% respectively.ConclusionsThe results reveal the benefits of the allogenic arterial grafts in revascularization in patients with major vascular prostheses infections. The differences in secondary patencies of the implanted allogenic grafts indicate the necessity of an early selection of patients for the complete removal of the infected prosthesis, during a time when patients are in general good health.

Combined surgical-endovascular treatment of multiple splenic artery aneurysms.

Accepted: 24 May 2004 Published online: 28 July 2004

Results from the International Silver Graft Registry for high-risk patients treated with a metallic-silver impregnated vascular graft

The purpose of this postmarket surveillance registry was to document the efficacy of a vascular prosthesis coated with metallic silver in high-risk patients undergoing vascular reconstructions. Patency (primary endpoint) and freedom from graft infection (secondary endpoint) data were assessed at a minimum of 12 months in patients with significant co-morbidity and/or confirmed graft infections or infected native vessels. Between November 2006 and December 2009, 230 patients with high-risk factors underwent aortic, peripheral and/or extra-anatomic reconstructions with Silver Graft® (SG) in six German, one French and one Polish vascular center. All participating centers used the metallic silver-coated polyester graft (SG) in various diameters and lengths including tubular and bifurcate vascular grafts. Doppler ultrasound follow-ups to determine graft patency were planned at 12 months or done at an earlier time in case the patient became symptomatic. A total of 230 patients were studied. Ten of these 230 patients had graft infections at baseline whereas the remaining 220 subjects had significant risk factors such as coronary artery disease (62.7%, 138/220), vascular access in scar tissue (27.3%, 60/220), Fontaine III/IV (38.2%, 84/220), chronic renal insufficiency (26.8%, 59/220) and diabetes (21.0%, 46/220). The long-term follow-up at 15.5 ± 8.3 months revealed a secondary patency rate of 93.2% (205/220) and an ‘all cause’ mortality rate of 18.6% (41/220). There was a freedom from de novo graft infection rate of 95.9% (211/220) in the high-risk group without graft infections at baseline. One regraft infection occurred distal of the revisional reconstruction in the 10 patients with graft infection at baseline. The presence of perigraft fluid at follow-up and Fontaine III/IV at baseline were found to be predictors for graft patency whereas perigraft fluid presence was the only predictor for de novo graft infections. This registry revealed favorable patency and freedom from de novo infections rates in a ‘high-risk’ population with significant co-morbidities.

Intramural Hematoma of the Thoracic Aorta as a Form of Aortic Dissection

Intramural hematoma (IMH) of the thoracic aorta is a complication with unknown etiology and a poorly predictable prognosis. There is also considerable controversy about the management and prognosis of IMH as well as the treatment. We present two cases of endovascular treatment of IMH with stent-graft placement. On the basis of references, we discuss risks of progression of the given pathology and possible complications. Despite the lack of uniform opinion about the management of this disorder, we present our observations of and experiences with endovascular treatment of IMH of the thoracic aorta.

Endovascular Treatment of Late Thoracic Aortic Aneurysms after Surgical Repair of Congenital Aortic Coarctation in Childhood

Background In some patients, local surgery-related complications are diagnosed many years after surgery for aortic coarctation. The purposes of this study were: (1) to systematically evaluate asymptomatic adults after Dacron patch repair in childhood, (2) to estimate the formation rate of secondary thoracic aortic aneurysms (TAAs) and (3) to assess outcomes after intravascular treatment for TAAs. Methods This study involved 37 asymptomatic patients (26 female and 11 male) who underwent surgical repair of aortic coarctation in the childhood. After they had reached adolescence, patients with secondary TAAs were referred to endovascular repair. Results Follow-up studies revealed TAA in seven cases (19%) (including six with the gothic type of the aortic arch) and mild recoarctation in other six (16%). Six of the TAA patients were treated with stentgrafts, but one refused to undergo an endovascular procedure. In three cases, stengrafts covered the left subclavian artery (LSA), in another the graft was implanted distally to the LSA. In two individuals, elective hybrid procedures were performed with surgical bypass to the supraaortic arteries followed by stengraft implantation. All subjects survived the secondary procedures. One patient developed type Ia endoleak after stentgraft implantation that was eventually treated with a debranching procedure. Conclusions The long-term course of clinically asymptomatic patients after coarctation patch repair is not uncommonly complicated by formation of TAAs (particularly in individuals with the gothic pattern of the aortic arch) that can be treated effectively with stentgrafts. However, in some patients hybrid procedures may be necessary.

Utility of Measurements of Abdominal Perfusion Pressure as a Measure of Isovolemic Status and Intestinal Perfusion in Patients with Ruptured Aortic Aneurysm

UNLABELLED Ruptured abdominal aorta aneurysm of ten results in intraabdominal hypertension (IAH). When IAH exceeds 20 mm Hg, intestinal ischemia can result that is a common cause of severe postoperative complications, including death. THE AIM OF THE STUDY was to evaluate utility of measurement of abdominal perfusion pressure (APP) to estimate intestinal perfusion and isovolemic status in patients undergoing surgical treatment for ruptured abdominal aorta aneurysm. MATERIAL AND METHODS A group of 40 patients of either sex, aged 47-93 years (average age 70 ± 10) was treated at an Intensive Care Unit after surgical reconstruction of abdominal aorta due to ruptured aortic aneurysm. The study was prospective. The following were measured: parameters of intraabdominal pressure (intraabdominal pressure - IAP, abdominal perfusion pressure - APP); parameters of intestinal perfusion - tonometric (intramucosal gastric carbon dioxide partial pressure PgCO(2), intramucosal-arterial difference in carbon dioxide partial pressure - Pg-aCO(2)); hemodynamic parameters (mean arterial pressure - MAP, central venous pressure - CVP). RESULTS A statistically significant correlation was demonstrated between parameters of visceral perfusion and abdominal perfusion pressure. Pearson correlation coefficient for APP/PgCO(2) and APP/Pg-aCO(2) was negative and was -0.4664 and -0.3498, respectively. CONCLUSIONS Abdominal perfusion pressure is an useful parameter in the evaluation of intestinal perfusion in IAH patients after surgical treatment of ruptured aortic aneurysm. MAP reflects current physiological body reserves at a critical stage of the disease, informing about possibility to provide visceral perfusion and indirectly, about adequacy of fluid replacement therapy. In intraabdominal hypertension, CVP is falsely elevated, making it of low utility in the evaluation of volemic status and intestinal perfusion.