Vladimir Makaloski

Self-Made Pericardial Tube Graft: A New Surgical Concept for Treatment of Graft Infections After Thoracic and Abdominal Aortic Procedures

BACKGROUND The aim of this study was to evaluate a new surgical concept for the treatment of graft infections after operation or endovascular treatment of thoracic, thoracoabdominal, and abdominal aortic diseases. METHODS Between 2004 and 2011, 15 patients (mean age 72 ± 10 years, 87% men) with prosthetic graft or endovascular graft infection were treated with complete removal of the infected prosthetic material, extensive debridement of the surrounding tissues, and orthotopic vascular reconstruction with self-made xenopericardial tube grafts constructed from a patch. Perioperative and long-term outcomes were evaluated. RESULTS Perioperative mortality was 27% (n = 4). All deaths were due to multiorgan failure resulting from uncontrolled septicemia from the local infectious process. Mean observational follow-up was 24 months (5 to 83 months). Control computed tomographic scans showed normal findings at the operative site in all patients. Antibiotic treatment was continued for a mean of 6 months. Freedom from reinfection was 100%. Freedom from reoperation was also 100%. CONCLUSIONS Treatment of graft infections after operation or endovascular treatment of thoracic, thoracoabdominal, and abdominal aortic diseases by complete removal of the infected prosthetic material and extensive debridement as well as orthotopic vascular reconstruction using self-made xenopericardial tube grafts as neoaortic segments provides excellent results with regard to durability and freedom from reinfection and reoperation. This new concept is an additional alternative to cryopreserved homografts that extends the armamentarium for treating patients with these highly complex conditions.

Thoracic endovascular aortic repair as emergency therapy despite suspected aortic infection

OBJECTIVES To evaluate thoracic endovascular aortic repair (TEVAR) as emergency therapy despite suspected aortic infection. METHODS Within a 5-year period, we treated 6 patients with a strategy of primary TEVAR despite suspected aortic infection in patients with symptomatic or already ruptured thoracic aortic pathology. RESULTS In-hospital mortality was 16.7%. The reason for death was septic multiorgan failure. During follow-up, 2 patients were converted to secondary open surgery in a stable elective setting. The median follow-up was 42.5 months. All surviving patients are not receiving continuing antibiotic therapy. Freedom from infection is 100% to date. CONCLUSIONS TEVAR as emergency therapy despite suspected aortic infection is feasible and may well serve as a definite treatment option in selected cases. As recurring infection cannot be entirely excluded, life-long clinical and morphological surveillance remains mandatory.

Combined Ascending Aortic Stent-Graft and Inner Branched Arch Device for Type A Aortic Dissection

Purpose: To report the use of the Zenith Ascend stent-graft in conjunction with the Zenith inner branched arch device to treat type A aortic dissection. Case Report: Five patients (mean age 66 years, range 52–78; 4 men) with type A aortic dissection (2 acute) and insufficient distal landing zones were treated with the Zenith Ascend stent-graft and inner branched arch devices to extend the distal landing zone. Left carotid–subclavian bypass was performed in a staged or simultaneous setting depending on the urgency of the condition. Technical success (no type I or III endoleak and successful revascularization of all supra-aortic vessels) was achieved in all patients. Median intensive care unit stay was 5 days (range 4–23) and the median hospital stay was 16 days (range 8–25). The 2 patients with acute dissection died in hospital and at 5 months, respectively. The 3 elective patients were followed for 7, 13, and 19 months, respectively. All had false lumen thrombosis with either a reduced or stable aneurysm diameter. Conclusion: This limited experience demonstrated the feasibility and safety of the combined use of the Ascend stent-graft and inner branched arch devices. This strategy may sometimes be more beneficial than either stent-graft used alone.

Popliteal vessel trauma: Surgical approaches and the vessel-first strategy

BACKGROUND In this study, we analyzed long-term outcomes following treatment of traumatic popliteal vascular injuries in an urban level I trauma center, using a vessel-first approach in the case of combined vascular and bony/ligamentous injuries and discussing the relative merits of the medial and posterior approach to popliteal vessels. METHODS Data including patient demographics, mechanism and type of injury, severity of limb ischemia, Injury Severity Score (ISS), limb ischemia time, time to revascularization from admission, treatment strategy, type of vascular reconstruction, limb salvage and mortality were retrospectively collected in patients treated for traumatic popliteal vessel lesions. All patients in this study were operatively treated using medial and posterior approaches. A vessel-first approach was used where possible. RESULTS Twenty-four patients (13 male) with a median age of 45 years (range 21-88) and popliteal vessel injury after traumatic knee dislocation (n = 10, 42%), proximal tibia fracture (n = 5, 21%), distal femur fracture (n = 4, 17%), blunt popliteal injury (n = 3, 12%) and penetrating trauma (n = 2, 8%) were identified. Twelve (50%) patients were treated via a medial approach and 12 (50%) via a posterior approach. All had injury of the popliteal artery (15 complete transection, eight local intimal disruption and one pseudoaneurysm) with seven having additional popliteal vein and five with nerve injury. Nineteen patients (88%) presented with limb ischemia Rutherford category ≥II. Vessel reconstruction (four direct sutures, four patch plasties, 16 venous interposition/bypasses) was performed prior to bone/joint stabilization in 22 patients (92%). Thirty-day mortality was zero. Two above-knee amputations were performed within 30 days due to severe infection. During a median follow-up of 59 (range 12-143) months, there were no deaths and no amputations. At the end of follow-up, all patients denied claudication. CONCLUSIONS The vessel-first strategy promises an excellent outcome, independent of the surgical approach needed to repair traumatic popliteal vessel injuries.

Fascial suture technique versus open femoral access for thoracic endovascular aortic repair

Background: Fascial suture technique (FST) has proved to be a safe and effective access closure technique after endovascular repair of the abdominal aorta. FST has not yet been investigated for closure of large‐bore access after thoracic endovascular aortic repair (TEVAR). The aim of this study was to compare FST with open femoral access in terms of access safety, hemostasis efficacy, and reintervention rate after TEVAR. Methods: A retrospective study including consecutive patients undergoing TEVAR with either FST or open femoral access between January 2010 and April 2016 was undertaken. Exclusion criteria included the use of closure devices. The composite primary end point was defined as any access‐related complication (bleeding, femoral artery stenosis or occlusion, pseudoaneurysm, and wound infection) during 30 postoperative days. Preoperative and procedural variables were examined in a multiple logistic regression model as potential associated factors with access morbidity. All access vessels were postoperatively examined by clinical examination and computed tomography angiography before discharge as well as during the follow‐up period. In case of suspected pseudoaneurysm, additional duplex ultrasound and computed tomography angiography confirmed the diagnosis. Results: From a total of 206 patients undergoing TEVAR, 109 (53%) had FST, whereas 93 (45%) had an open femoral access. Four patients were excluded: closure device was used in one; one had primary conversion after percutaneous puncture without FST; and in two, no data were available about the femoral access. The access complication rate was higher in FST (FST, 14 [13%]; open access, 3 [3%]; P = .01). Five (4.6%) patients needed early reintervention, two for bleeding and three for vessel occlusion. Seven (6.4%) pseudoaneurysms were detected during the 30‐day period in the FST group; three had successful exclusion with thrombin injection, one was treated with manual compression, one was treated with open repair, and two were managed conservatively. Four (3.6%) patients in the FST group and three (3%) patients in the open access group had wound complications. After multiple logistic regression, FST was the only independent factor for any access complication (odds ratio, 5.176; 95% confidence interval, 1.402‐19.114; P = .014). During follow‐up, neither new pseudoaneurysm nor stenosis or occlusion was detected. Conclusions: FST for large‐hole closure had higher risk for any access complication compared with open access in TEVAR during the 30‐day postoperative period. No other complications during 12 months of follow‐up were observed in FST patients.