Literature review on management of prosthetic graft infections after supra-aortic bypass surgery, based on a case report.

BACKGROUND: Graft infections of supra-aortic bypasses are rare, but often life-threatening. Guidelines for treatment of graft infections recommend systemic antibiotics and complete graft removal, followed by in-situ or extra-anatomic revascularisation. METHODS: Based on case report, literature search was performed on Medline, Google Scholar and Web of Science databases, focussing on infected supra-aortic bypass reconstructions. Inclusion criterium was prosthetic graft infection, excluding stent and carotid patch infections. RESULTS: A 68-year old man with clinically infected subclavian-subclavian bypass with interposition bypass to left carotid bifurcation, presented at emergency department with manifestation of sepsis. A total graft removal and an extra-anatomical prosthetic reconstruction was created, from right common carotid artery to left carotid bifurcation. Defect of prior left subclavian anastomosis was primarily closed, on right subclavian anastomosis per-operative acute bleeding occured, which was controlled by covered stent through right brachial artery. Literature review identified 16 cases. Different approaches ranging from open repair with autologous (six) or allogenic (two) material, to hybrid techniques (eight) have been described. No re-infections were reported. When comparing different types of approaches, no differences are found concerning overall complications. CONCLUSION: Complete graft removal with extra-anatomical reconstruction is challenging, but crucial in supra-aortic graft infections. Preservation of parts of vascular prosthesis depends on case-by-case basis, according to infection site and general condition of the patient. But due to rarity, only case reports are available, so no strong recommendations can be formulated. International registries should be initiated to share experiences and provide data for decent analysis of short, mid and long term outcomes.

Surgical treatment of therapy-resistant reflux after Roux-en-Y gastric bypass. A case series of the modified Nissen fundoplication.

Introduction: Patients with intractable reflux after RYGB have limited treatment options. Here a modified Nissen fundoplication (MNF) as described by N. Kawahara might be the answer.Methods: In this retrospective case study we identified six patients with therapy-resistant GERD after RYGB. All six were treated with a MNF, using the remnant stomach to construct the fundoplication. Short term follow-up 1 month and 6-12 months postoperatively was conducted to inquire about GERD symptoms.Results: Six patients underwent a MNF. Three out of six patients had had a gastric band in their medical history. Upper GI barium swallow test revealed herniation of the gastric pouch in 4/6 patients. After surgery all patients were symptom free and 4/6 completely stopped PPI treatment.Discussion: Mechanisms of new onset or deteriorating GERD after RYGB are herniation of gastric pouch and destruction of the lower esophageal sphincter after banding. Both problems are tackled when constructing a MNF.Conclusion: Complete symptom relief was seen 1 month after MNF. The procedure seems safe, feasible and effective. The study is limited by small sample size and short follow-up yet shows clear improvement of symptoms. Larger trials are needed to establish validity of the MNF.

Spontaneous Isolated Bilateral Iliac Artery Dissection in a Patient with Relapsing Polychondritis.

INTRODUCTION: Isolated iliac artery dissection (IAD) is a rare form of arterial dissection. The most commonly known causes of non-traumatic isolated iliac dissection are connective tissue diseases. Relapsing polychondritis (RP) is a rare inflammatory and multisystemic disease, typically affecting cartilage and connective tissue. Cardiovascular complications occur in approximately 25% of patients with RP. CASE DESCRIPTION: The first case of spontaneous isolated bilateral iliac artery dissection in a patient with RP is reported. A 48-year-old woman presented with a two year history of severe right leg intermittent claudication (Rutherford category 3). The complaints were initially attributed to joint pathology associated with RP. However, clinical examination and computed tomography angiography led to a diagnosis of bilateral IAD. A dissection in the left common iliac artery (CIA) began at its origin and ended at the origin of the internal iliac artery, with the true and false lumen both comprising half of the entire lumen. The right CIA was completely occluded from its origin to the origin of the right internal iliac artery. The patient was treated endovascularly by bilateral CIA stent placement with covered stent grafts (Bentley BeGraft), 8 × 57 mm on the right side and 8 × 37 mm on the left. The patient recovered pedal pulses, the stent remained patent, and the patient was asymptomatic at the one month follow-up. DISCUSSION: Early identification of intermittent claudication is necessary to prevent the progression of complications in patients with RP. Vascular surgeons should be aware of IAD as the potential first presentation of underlying systemic disease. Internists should also keep vascular complications in mind in patients with systemic diseases like RP suffering from unexplained complaints in the lower limbs, undertake a basic vascular examination, and make a vascular referral where appropriate.

Fenestrated and branched endovascular repair for juxtarenal and thoracoabdominal aortic aneurysms: analysis of the first 100 cases.

BACKGROUND: Endovascular aortic aneurysm repair (EVAR) has become the most popular technique to treat infrarenal abdominal aortic aneurysms. In aneurysms with unsuitable anatomy open surgical repair remains the golden standard but fenestrated EVAR (FEVAR) or branched EVAR (BEVAR) may be an alternative to treat juxtarenal or thoracoabdominal aneurysms. The aim of this study was to report our results and to evaluate its safety and feasibility. METHODS: This is a single center cohort study analyzing all consecutive patients undergoing FEVAR or BEVAR. RESULTS: One hundred patients underwent a procedure between June 2012 and December 2019. Forty-seven percent had a history of coronary artery disease and 31% of previous aortic repair. Sixty percent were treated for a juxtarenal and 40% for a TAAA. Primary technical success was 87%. Overall, thirty-day mortality was 6%, with 50% of the deaths resulting from a myocardial infarction. Four percent had a bowel resection for ischemia, 3% developed a stroke and 3% spinal cord ischemia. Mean follow-up was 33.6±22.4 months, freedom from all-cause mortality was 89.3±3.2% at one year and 66.4±7.6% at five years. Six intraoperative target vessel events were noted (1.7%), six early postoperative (1.7%) and three late (0.8%). A total of ten (10%) late procedure related secondary interventions were performed, among which six for endoleak. CONCLUSIONS: This study confirms that fenestrated and branched endovascular repair is a safe and feasible treatment for juxtarenal and thoracoabdominal aortic aneurysms with acceptable complication rates. The perioperative cardiac mortality highlights the importance of preoperative risk assessment and patient selection.

Aortic valve replacement due to granulomatosis with polyangiitis: a case series.

BACKGROUND: Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, is a systemic inflammatory process predominantly affecting upper and lower respiratory tract and kidneys. Valvular heart disease is a rare manifestation of GPA. CASE SUMMARY: We report two cases of acute valvular heart disease mimicking acute endocarditis caused by GPA. Both patients were middle-aged females with acute aortic valve regurgitation suggestive of possible infective endocarditis. In their recent medical history, atypical otitis and sinusitis were noted. The first patient was admitted with heart failure and the second patient because of persisting fever. Echocardiogram revealed severe aortic regurgitation with an additional structure on two cusps, suggestive of infective endocarditis in both patients. Urgent surgical replacement was performed; however, intraoperative findings did not show infective endocarditis, but severe inflammatory changes of the valve and surrounding tissue. In both patients, the valve was replaced by a prosthetic valve. Microscopic examination of the valve/myocardial biopsy showed diffuse acute and chronic inflammation with necrosis and necrotizing granulomas, compatible with GPA after infectious causes were excluded. Disease remission was obtained in both patients, in one patient with Rituximab and in the other with Glucocorticoids and Cyclophosphamide. Both had an uneventful follow-up. DISCUSSION: Granulomatosis with polyangiitis can be a rare cause of acute aortic valve regurgitation mimicking infective endocarditis with the need for surgical valve replacement. Atypical ear, nose, and throat symptoms can be a first sign of GPA. Symptom recognition is important for early diagnosis and appropriate treatment to prevent further progression of the disease.