Physician Made Bovine Pericardial Tube Grafts in Aortic Infection: A European Multicentre Study.

OBJECTIVE: This study examines outcome and durability of physician made bovine pericardial tube grafts in aortic infections in all anatomical locations. METHODS: This was a retrospective and prospective international multicentre study. Peri-operative and long term outcomes of patients undergoing in situ aortic reconstruction for native or graft infections with physician made bovine pericardial tube grafts between January 2008 and December 2020 in four European tertiary referral centres were analysed. The primary endpoint was recurrent aortic infection. Secondary endpoints were persistent infection, aortic re-operation for infection, graft related complications, and death. RESULTS: One hundred and sixty eight patients (77% male, mean age 67 ± 11 years) were identified: 38 (23%) with native and 130 (77%) with aortic graft infection. The thirty day mortality rate was 15% (n = 26) overall, 11% (n = 4), and 17% (n = 22) for native and aortic graft infections, respectively (p = .45). Median follow up was 26 months (interquartile range [IQR] 10, 51). Estimated survival at one, two, three, and five years was 64%, 60%, 57%, and 50%, and significantly better for native (81%, 77%, 77%, and 69%) than for graft infections (58%, 55%, 51%, and 44%; p = .011). Nine patients (5.3%) had persistent infection and 10 patients (6%) had aortic re-infection after a median of 10 months (IQR 5, 22), resulting in an estimated freedom from re-infection at one, two, three, and five years of 94%, 92%, 90%, and 86%. Estimated freedom from graft complications at one, two, three, and five years was 91%, 89%, 87%, and 87%. CONCLUSION: This multicentre study demonstrates low re-infection rates when using physician made bovine pericardial tube grafts, comparable to those of other biological grafts. The rate of graft complications, mainly anastomotic aneurysms and stenoses, was low, while graft degeneration was absent. Physician made bovine pericardial tube grafts are an excellent tool for in situ reconstruction in the setting of native aortic infection or aortic graft infection.

Outcomes post Ozaki procedure among children with aortic valve disease at Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania: a retrospective descriptive study.

BACKGROUND: Aortic valve reconstruction using glutaraldehyde-treated autologous pericardium, also called Ozaki procedure, is a surgical procedure for patients with aortic valve disease. Gratifying results have been reported in adult patients, however, limited published data is available in paediatric population. This study looked at clinical characteristics and early outcomes of children who underwent Ozaki procedure at our Institute. METHODS: This was a retrospective descriptive study conducted on children who underwent aortic valve reconstruction at Jakaya Kikwete Cardiac Institute (JKCI) from January 2019 through December 2022. Medical records of these children were reviewed to extract data on demographics, clinical characteristics, redo surgical interventions and survival. RESULTS: A total of 10 children underwent Ozaki procedure during the study period. Eight children had severe aortic regurgitation while 2 had severe aortic stenosis preoperatively. All children had either none or trivial aortic regurgitation immediately after surgery. None of them had redone operations throughout the follow-up period. There was no in-hospital mortality, however, one child died one-year after surgery. The mean follow-up period was 1.6 years with the longest follow-up time of 4 years. CONCLUSION: Ozaki procedure showed encouraging early results among children with aortic valve disease who underwent surgical repair by this technique. Future studies with larger sample sizes and longer follow up periods to evaluate long-term results in this population are recommended.

Antibiotic Efficacy against Methicillin-Susceptible Staphylococcus aureus Biofilms on Synthetic and Biological Vascular Grafts.

BACKGROUND: Biofilm formation is one of the greatest challenges encountered in vascular graft infections. Our aim is to compare the efficacy of 5 antibiotics against methicillin-susceptible Staphylococcus aureus (MSSA) biofilms on the surface of 4 vascular grafts. METHODS: In vitro study of 2 clinical MSSA strains (MSSA2 and MSSA6) and 4 vascular grafts (Dacron, Dacron-silver-triclosan (DST), Omniflow-II, and bovine pericardium). After a 24-hr incubation period, the graft samples were divided into 6 groups: growth control (no treatment), ciprofloxacin 4.5 mg/L, cloxacillin 100 mg/L, dalbavancin 300 mg/L, daptomycin 140 mg/L, and linezolid 20 mg/L. Quantitative cultures were obtained and results expressed as log10 colony-forming units per milliliter (CFU/mL). Analysis of variance was performed to compare biofilm formation between the different groups. RESULTS: The mean ± standard deviation MSSA2 count on the growth control Dacron graft was 10.05 ± 0.31 CFU/mL. Antibiotic treatment achieved a mean reduction of 45%; ciprofloxacin was the most effective antibiotic (64%). Baseline MSSA2 counts were very low on the DST (0.50 ± 1.03 CFU/mL) and Omniflow-II (0.33 ± 0.78 CFU/mL) grafts. On the bovine pericardium patch, the count was 9.87 ± 0.50 CFU/mL, but this was reduced by a mean of 45% after antibiotic treatment (61% for ciprofloxacin). The mean MSSA6 count on the growth control Dacron graft was 9.63 ± 0.53 CFU/mL. Antibiotics achieved a mean reduction of 48%, with ciprofloxacin performing best (67% reduction). The baseline MSSA6 count on the DST graft was 8.54 ± 0.73 CFU/mL. Antibiotics reduced biofilm formation by 72%; cloxacillin was the most effective treatment (86%). The MSSA6 count on the untreated Omniflow-II graft was 1.17 ± 1.52 CFU/mL. For the bovine pericardium patch, it was 8.98 ± 0.67 CFU/mL. The mean reduction after antibiotic treatment was 46%, with cloxacillin achieving the greatest reduction (68%). CONCLUSIONS: In this in vitro study, ciprofloxacin and cloxacillin performed best at reducing biofilms formed by clinical MSSA strains on the surface of biological and synthetic vascular grafts.

Treatment of Aorto-iliac and Infrainguinal Vascular Infections with a Prefabricated Bovine Pericardial Graft.

BACKGROUND: The use of biological grafts provides acceptable mid- and long-term results in native or prosthetic vascular infections. Several reports describe the successful use of bovine pericardium in case of vascular infections, mainly as a large patch to be sutured as a tubular graft. Recently, a novel prefabricated bovine pericardium graft (Biointegral Surgical No-React® Inc, Mississauga, ON, Canada) has been introduced in clinical practice with promising results. In this study, we report our preliminary experience utilizing Biointegral Surgical graft in case of native and or prosthetic aorto-iliac and infrainguinal infection. METHODS: We retrospectively analyzed data from 20 patients with native or prosthetic aorto-iliac and infrainguinal infection who underwent in situ reconstruction (ISR) with a Biointegral Surgical No-React bovine pericardium prosthesis between October 2020 and February 2023 at the Vascular Surgery Unit of the Fondazione Policlinico Universitario Gemelli - IRCCS in Rome, Italy. All patients followed a standardized protocol including postoperative anticoagulation and long-term intravenous antibiotics. RESULTS: The indication for surgery was: mycotic aortic aneurysm in 4 patients (20%), graft infection after abdominal aortic repair in 11 patients (55%), peripheral graft infection in 5 patients (25%). Complete excision of the infected aorta or prosthetic graft, surgical debridement and ISR were performed in all patients. Hospital mortality rate was 5% (n = 1) and graft-related mortality of 0%. During follow-up (median 13 months, range 6-34 months), reinfection was 5.2% and primary graft patency 94.7%. CONCLUSIONS: The use of prefabricated bovine pericardial grafts represents a promising option for the treatment of native and prosthetic aorto-iliac and infrainguinal infections. The application of this biological graft with a standardized postoperative protocol has been associated with a satisfactory patency and reinfection rate without increased bleeding complications.

Outcomes Following Use of Bovine Pericardium (Xenoprosthetic) Grafts for Reconstruction of Mycotic Aortic Aneurysms and Infected Aortic Grafts: A Systematic Review and Meta-Analysis.

BACKGROUND: Infected aortic grafts and mycotic aneurysms represent one of the most complex challenges faced by vascular surgeons. Treatment has progressed from extra-anatomical bypass to in situ reconstruction. Additionally, bovine pericardium reconstruction (BPR) has increased, due to accessibility and reduced lower limb morbidity. There remains, however, limited evidence for its use. The aim is to pool all known data to understand outcomes following BPR of mycotic aneurysms or infected vascular grafts. METHODS: A systematic review was conducted in November 2021 with subsequent computerized meta-analysis of the pooled results and a final search in March 2022. Three databases, Excerpta Medica dataBASE (EMBASE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), and National Institutes of Health PubMed (PubMed), were searched for the search term "(bovine OR xenoprosthetic) AND (aneurysm)", according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: From 9 studies, there were 133 patients: 67% graft infections and 33% mycotic aneurysms. Fifty-seven percent of reconstructions were in the abdominal aorta and 33% were in the thoracic aorta. One hundred fifty-eight pathogens were identified, including Staphylococcus aureus (23%), Candida albicans (13%), and Escherichia coli (13%). In 12%, no microorganisms were identified. Thirty-day mortality was 19.14% (CI 10.83-28.71), late mortality was 19.08% (confidence interval [CI] 7.76-32.83), and overall mortality was 40.20% (CI 29.82-50.97). One patient died intraoperatively. There were a total of 151 in-hospital complications after 30 days postoperation. Common complications were acute renal failure (17%), pneumonia (14%), delirium (12%), respiratory insufficiency (11%) and renal insufficiency (7%). Lower limb ischemia was low, occurring in 5.66% (CI 0.54-13.82) of patients. Loss of graft patency leading to reintervention occurred in 1.20% (CI 0.00-7.71) of the grafts. Reinfection rate was 0.00% (CI 0.00-1.21). CONCLUSIONS: This meta-analysis highlights low reinfection and high graft patency using BPR with medium-length follow-up; however, there remain limited long-term and comparative data regarding options for aortic reconstruction. As expected in this complex cohort, the complication rate and 30-day mortality remain high.

Treatment of an Exposed Achilles Tendon within a Refractory Mixed Arterial Venous Leg Ulcer with the Novel Use of Pericardium Allograft in Combination with Amniotic Allografting, Synthetic Extracellular Matrix, and Acellular Dermis Allografting: A Case Report.

Xenografts, commonly from porcine or bovine sources, have decades-long documented use in reconstructive surgery, including the repair of Achilles tendons. Despite decellularization processes, the risk of antigenicity with xenografts still poses a threat for graft failure. Allograft tissues reduce the risk of immune response and provide greater likelihood of successful grafting. SteriGraft® Pericardium (BSP) (Bone Bank Allografts, San Antonio, Texas) is a lyophilized allograft obtained from the pericardial sac that has undergone sterilization and processing for use in the surgical repair. The aim of this case study was to highlight the novel use of human pericardium allograft in the repair of an exposed Achilles tendon within a vascular ulceration with the concomitant use of synthetic extracellular matrix, amniotic allografting, dermal allografting, and negative pressure wound therapy to achieve healing of the wound and restoration of limb function.

Comparison of autologous venous grafts and three types of extracellular matrix grafts in Peyronie's disease surgery.

Background/aim: Peyronie's disease (PD) is known as a wound-healing disorder for which surgery remains the gold-standard treatment, but studies comparing graft materials are limited in the literature. The aim of this study was to evaluate the mid- and long-term results of patients who underwent surgery for PD with grafting procedures performed by a single experienced surgeon according to graft materials. Materials and methods: Patients who underwent corporoplasty between 2014 and 2020 with grafting procedures performed by a single experienced surgeon were retrospectively reviewed. A total of 115 patients were divided into 4 groups according to the grafting material used: autologous saphenous venous grafts, Group 1 (n = 36); porcine pericardial extracellular matrix grafts (EMGs; XenoGuard, MBP Medical Biomaterial Products GmbH, Neustadt-Glewe, Germany), Group 2 (n = 40); porcine intestinal submucosal EMGs (BioDesign, Cook Medical, Bloomington, IN, USA), Group 3 (n = 36); and bovine pericardial EMGs (Tutopatch, Tutogen Medical, Inc., Alachua, FL, USA), Group 4 (n = 43). Results: The mean operation time for Group 1 was longer than that of the other groups (p < 0.001). When comparing the groups in pairs, it was observed that the duration of postoperative loss of sensation (LOS) was significantly shorter in Group 3 (12.3 ± 5.3 days) and Group 4 (15.1 ± 3.1 days) (p < 0.05). There was a statistically significant difference between Groups 1 and 4 in penile length loss when the groups were compared in pairs (p = 0.017). There was a statistically significant difference between patients with penile curvatures of 0° to 59° and patients with curvatures of ≥60° in terms of duration of postoperative LOS (14.4 ± 5 vs. 16.4 ± 5.8 days, respectively; p = 0.028) and penile length loss (2.6 ± 5 vs. 5.7 ± 6.8 mm, respectively; p = 0.002). Conclusion: The findings suggest that EMGs should be preferred to autologous venous grafts due to reduced postoperative erectile dysfunction, shorter operation time, and shorter recovery time for LOS.

Partial Tracheal Defects Closure using Glutaraldehyde-Treated Autologous Pericardium.

BACKGROUND: The usefulness of autologous pericardium treated with glutaraldehyde (GA) for tracheal defect closure is unknown. This study preliminarily evaluated whether a GA-treated autologous pericardial graft can effectively close tracheal defects in a beagle model. METHODS: Defects of 10 mm × 10 mm were created on the trachea of 10 beagles and divided into a GA-treated group (n = 5), with tracheal reconstruction using GA-treated pericardium, and control group (n = 5), using fresh pericardium. Repair sites were evaluated through bronchoscopy and histology. Blood flows on graft were measured using laser Doppler technique on postoperative days (PODs) 0, 4, 7, 14, 28, and 56. Repair sites were histologically evaluated on POD 56. In addition, GA-treated pericardia of three other beagles were histologically evaluated 12 months postoperatively, for long-term follow-up. RESULTS: All animals survived; none developed anastomotic insufficiency. The mean suturing time and frequency of additional suture were significantly shorter and lower in the GA-treated group than in the control group (p = 0.002, 0.004). All animals in the control group exhibited graft contraction, whereas the GA-treated group healed with most graft residual and reepithelialization in the bronchoscopic and histological findings (p = 0.01, 0.004). Further, all long-term GA-treated pericardia of three beagles were confirmed as residual grafts with reepithelialization, without contraction, at 12 months postoperatively. Blood flows on graft using laser Doppler technique in the GA-treated group were detected at POD 14 or thereafter. CONCLUSION: GA-treated pericardium was easier to handle and provided favorable scaffolding, without graft contraction, compared with the nontreated pericardium at short- and long-term follow-up.

Outcomes of vein reconstruction using bovine pericardial patch.

BACKGROUND: The bovine pericardium is a good alternative material to the autogenous vein in vascular reconstruction. This study aimed to evaluate the results of angioplasty in venous reconstruction using bovine pericardium and identify the risk factors for significant complications. MATERIAL AND METHODS: A retrospective review was performed of the demographic data, clinical characteristics, and complications of patients who underwent vessel repair using bovine pericardium between February 2012 and December 2020. Univariate analysis was used to compare complication frequencies within several categories. RESULTS: There were 36 cases of patch angioplasty using bovine pericardium. The median age was 65 years; 61% of them were men. Of the 36 venous repairs, 31 (86.1%) were from cancer surgery and five (13.9%) were from iatrogenic injury. Patch shape was used in 27 cases (75.0%), while tube shape was used in nine cases (25.0%). The incidence of occlusion and partial thrombus was five (13.9%) and three (8.3%) cases, respectively. Of the nine tube-shaped angioplasties, four (44.4%) required reoperation due to early thrombosis (three cases) and hematoma (one case). CONCLUSION: The use of a bovine pericardial patch in the reconstruction of a damaged vein from tumor invasion or iatrogenic injury is feasible. However, the complication rate of vessel patency remains substantial, especially in cases of iatrogenic injury or when a tube-shaped form is used for repair.

Aortic valve neocuspidization using autologous pericardium compared to surgical aortic valve replacement.

INTRODUCTION: Aortic valve neocuspidization (AVNeo) for trileaflet aortic valve reconstruction using autologous pericardium (Ozaki procedure) depicts an encouraging new technique for the surgical treatment of aortic valve pathologies. The current study analyzes the early hemodynamic outcome of AVneo compared with surgical aortic valve replacement (SAVR) using the Abbott/St. Jude Trifecta aortic valve biological prostheses. METHODS: All patients who underwent either AVNeo or SAVR between March 2017 and April 2020 were included. Exclusion criteria were emergency cases, endocarditis, redo- or additional root procedures. Main endpoints were differences between the two groups in terms of the effective orifice area (EOA) and the effective orifice area index (EOAI) at discharge. RESULTS: During the study period, 105 AVNeo patients and 458 SAVR patients met the inclusion criteria. EOA was significantly higher in the AVNeo group (2.4 cm2 ± 0.8 vs. 2.1 cm2 /m2 ± 0.6 in the SAVR group, respectively; p < .001). Multiple regression analysis, including AVNeo, annulus size, bicuspid valve, preoperative stenosis, left ventricular ejection fraction (LVEF), and diastolic diameter (LVEDD) found two factors, which favor larger EOA: Annulus size (p < .0001) and AVneo (p = .005). EOAI was significantly higher in the AVNeo group (1.23 ± 0.4 vs. 1.02 cm2 /m2 ± 0.3, respectively; p < .001). Multiple regression analysis for EOAI showed effects for AVneo (p = .005) and bicuspid valve (p = .029). Mean pressure gradients (MPG) were lower in the AVNeo group than in the SAVR group (AVNeo: MPG = 8.0 mmHg ± 3.6 vs. SAVR: MPG = 8.3 mmHg ± 3.6), but this finding did not reach statistical significance (p = .091). CONCLUSIONS: AVNeo shows significantly larger EOA and EOAI compared to SAVR using the Abbott/St. Jude Trifecta aortic valve biological prostheses.

"Y" incision and rectangular patch enlargement of aortic annulus and valve reconstruction with autologous pericardium in congenital aortic stenosis.

Surgical aortic valve replacement in children who have undergone prior balloon or surgical valvuloplasty or both is a formidable challenge. The aortic annulus is small, there is no ideal prosthesis and lifelong anticoagulation is highly undesirable. A "Y" incision and rectangular patch enlargement of the aortic annulus introduced by Dr. Bo Yang in 2020 combined with aortic valve reconstruction introduced by Dr. Shigeyuki Ozaki in 2011, is feasible, as described in this case.

Aortic valve neocuspidization using autologous versus bovine pericardium: Ozaki versus Batista.

BACKGROUND: The average living age of the population is constantly increasing and so is the incidence and prevalence of aortic valve disease. Surgical aortic valve replacement (SAVR) is the current gold standard treatment. Nevertheless, the use of prosthetic valves in SAVR is associated with issues that impact patients' quality of life. Aortic valve neocuspidization (AV Neo) offers a means to solve this dilemma by minimizing foreign valve tissue. AV Neo can either be performed using glutaraldehyde-treated autologous pericardium (Ozaki procedure) or bovine pericardium (Batista procedure). AIMS: This commentary aims to discuss the recent study by Chan and colleagues which highlighted the surgical approach, clinical outcomes, and limitations of the Ozaki procedure, and compare this to the Batista procedure. METHODS: A comprehensive literature search was performed using multiple electronic databases including PubMed, Ovid, Embase, and Scopus to collate the relevant research evidence. RESULTS: Although the Ozaki procedure can achieve favorable results whilst mainly avoiding the need for life-long oral anticoagulation with mechanical valves, it still has several limitations that may hinder results. AV Neo using glutaraldehyde-treated bovine pericardium, developed by pioneer cardiac surgeon Dr. Randas J. Vilela Batista, yields superior clinical outcomes to Ozaki's, including excellent survival, lower complications, and minimal need for reoperation as well as shorter operative times. CONCLUSION: AV Neo offers a means to perform SAVR whilst escaping the prosthetic valve issues. However, the Batista procedure has shown beyond doubt that it can be considered the superior approach for AV Neo over the Ozaki procedure.

Aortic valve reconstruction surgery using autologous pericardium: The experience in Vietnam.

OBJECTIVE: The study aimed to evaluate the indications and describe the aortic valve reconstruction techniques by Ozaki's procedure in Vietnam and report mid-term outcomes of this technique in Vietnam. METHODS: Between June 2017 and December 2019, 72 patients diagnosed with isolated aortic valve disease, with a mean age of 52.9 (19-79 years old), and a male:female ratio of 3:1 underwent aortic valve reconstruction surgery by Ozaki's technique at Cardiovascular Center, E Hospital, Vietnam. RESULTS: The aortic valve diseases consisted of aortic stenosis (42%), aortic regurgitation (28%), and a combination of both (30%). In addition, the proportion of aortic valves with bicuspid morphology and small annulus (≤21 mm) was 28% and 38.9%, respectively. The mean aortic cross-clamp time was 106 ± 13.8 min, mean cardiopulmonary bypass time was 136.7 ± 18.5 min, and 2.8% of all patients required conversion to prosthetic valve replacement surgery. The mean follow-up time was 26.4 months (12-42 months), the survival rate was 95.8%, the reoperation rate was 2.8%, and rate of postoperative moderate or higher aortic valve regurgitation was 4.2%. Postoperative valvular hemodynamics was favorable, with a peak pressure gradient of 16.1 mmHg and an effective orifice area index of 2.3 cm2 . CONCLUSIONS: This procedure was safe and effective, with favorable valvular hemodynamics and a low rate of valvular degeneration. However, more long-term follow-up data are needed.

Auto-Pericardial Mitral Valve Implantation: A Pilot Study.

INTRODUCTION: Developing nations continue to grapple with rheumatic heart disease, particularly in the young. There is a need for an alternative to prosthetic mitral valve replacement in irreparable mitral valves, which avoids the need for anticoagulation and risks of thromboembolism. METHODS: Twelve (12) patients with irreparable severe mitral valve disease underwent auto-pericardial mitral valve implantation from August 2020 to February 2021. The mitral valve leaflets were excised. Autologous pericardium treated with 0.5% glutaraldehyde for 8 minutes was fashioned into anterior and posterior mitral leaflets as per the dimensions on an indigenously designed template based on the studies by Ranganathan and Lam. The pericardial leaflets were sutured onto an appropriately sized mitral annuloplasty ring. The ring with the leaflets was implanted onto the mitral annulus. The leaflets were supported with neo-chordae prepared with Gore-Tex (W L Gore and Associates, Inc. Newark, DE, USA) and polyester sutures to mimic a repaired mitral valve in its structure and dynamics. RESULTS: The mean cross-clamp time was 138±21.7 minutes. None of the patients required re-exploration. On the third postoperative day, a mean mitral valve orifice area of 3±0.47 cm and mean mitral valve gradient of 2±1.04 were observed. None of the patients had any more than 1+ mitral regurgitation. None of them have required a re-intervention for mitral insufficiency to date. DISCUSSION: Auto-pericardial mitral valve re-implantation is a safe and effective procedure for severe, irreparable, mitral valve pathologies. However, the mid-term and long-term results need to be compared with conventional mitral valve replacement with a prosthetic valve in a randomised controlled trial.

[Midterm Outcomes of Pulmonary Valve Leaflet Augmentation using Fresh Autologous Pericardium for Transannular Patch Repair of Tetralogy of Fallot].

BACKGROUND: Although valve sparing (VS) for patients with smaller pulmonary valves has been increasing, transannular patch repair( TAP) accounts for more than half of the total tetralogy of Fallot corrections worldwide. We use fresh autologous pericardial patches to perform a modified TAP procedure with pulmonary valve leaflet augmentation as proposed by Sung et al. We aimed to explore the early and midterm outcomes of this procedure. METHODS: We retrospectively reviewed 37 patients( group TAP:12;group VS:25) who underwent total tetralogy of Fallot corrections from April 2018 to December 2021. RESULTS: No midterm mortality was observed at a median observation period of 20.4 months in both groups. The midterm rates of freedom from moderate or more pulmonary regurgitation( PR) were 64.2 % and 21.4% in group TAP and 100% and 100% in group VS at 1 and 3 years, respectively( p<0.001). The midterm rates of freedom from pulmonary stenosis reintervention were 100% and 100% in group TAP and 96% and 96% in group VS at 1 and 3 years, respectively( p=0.51). CONCLUSIONS: TAP showed acceptable midterm survival and reintervention rate. Longer follow-up is essential considering the significantly higher PR in the postoperative period in group TAP.

Early outcomes of native and graft-related abdominal aortic infection managed with orthotopic xenopericardial grafts.

OBJECTIVE: Reconstruction of infected aortic cases has shifted from extra-anatomic to in situ. This study reports the surgical strategy and early outcomes of abdominal aortic reconstruction in both native and graft-related aortic infection with in situ xenopericardial grafts. METHODS: Included in the analysis are 21 consecutive patients (mean age, 69 years; 20 male) who underwent abdominal xenopericardial in situ reconstruction of native aortic infection (4) and endovascular (4) or open (13) graft aortic infection between July 2017 and September 2019. All repairs were performed on an urgent basis, but none were ruptured. All patients were followed up with clinical and biologic evaluation, ultrasound at 3 months, and computed tomography scan at 6 months and 1 year. RESULTS: Technical success was 100%; 8 patients were treated with xenopericardial tubes and 13 with bifurcated grafts. Thirty-day mortality was 4.7% (one death due to pneumonia with respiratory hypoxic failure in critical care.). Six patients (28%) developed acute kidney injury, four (19%) requiring temporary dialysis; five fully recovered and one died. Four patients (19%) required a return to the operating room. After a median follow-up of 14 months (range, 1-26 months), overall mortality was 19% (n = 4). Two patients presented with recurrent sepsis after reconstruction, leading to death due to multiorgan failure. Other patients (17/21) have discontinued antibiotics with no evidence of recurrence of infection clinically, radiologically, or on blood tests. Computed tomography scans at 1 year demonstrated no stenosis or graft dilation and one asymptomatic left graft branch thrombosis. Primary patency is 95%. CONCLUSIONS: In situ xenopericardial aortic reconstruction is a safe and effective management strategy for both native and graft-related abdominal aortic infection with good short-term results. The graft demonstrates appropriate resistance to infection such that reliable eradication of infection in this vascular bed is possible. Longer follow-up is required in future studies to determine the durability of the reconstruction and need for reinterventions.

A novel technique using long segment patch angioplasty maturation to increase the maturation rate of arteriovenous fistulas.

OBJECTIVE: Given the superior patency of arteriovenous fistulas (AVFs) and the decreased risk of infection compared with arteriovenous grafts, the Kidney Disease Outcomes Quality Initiative guidelines have recommended the fistula-first approach. However, ∼20% to 60% of all fistulas will fail to mature. We have described our experience with a novel technique using bovine pericardial patch angioplasty to increase the rate of AVF maturation. METHODS: We used 2-cm × 9-cm-long or 2.5-cm × 15-cm-long segment pericardial patch angioplasty to assist in the maturation of AVFs. A single-center, retrospective cohort study was conducted of all patients who had undergone patch angioplasty maturation (PAM) for AVFs that had failed to mature. The outcomes of interest were maturation status and patency, censored by the death and last known follow-up dates. RESULTS: From March 2007 to October 2019, 139 patients had undergone PAM. Follow-up data were available for 137 of the 139 patients (98.6%), with 126 AVFs (92.0%) progressing to maturation. Of the 126 patients with AVFs that had progressed to maturity, the previous hemodialysis (HD) method was known for 88 patients (69.8%). Of these 88 patients, 70 (79.5%) had previously been receiving HD via an HD catheter. Using a Kaplan-Meier estimator censored for death and loss to follow-up, the assisted primary patency rates at 1, 2, and 3 years were 87.3%, 78.1%, and 68.0%, respectively. Of the 137 patients, 69 (54.8%) had required no additional interventions after patch angioplasty. The complications requiring intervention were stenosis (n = 45; 32.8%), thrombosis (n = 10; 7.3%), infection (n = 3; 2.2%), steal syndrome (n = 3; 2.2%), noninfected wound complications (n = 1; 0.8%), and pseudoaneurysm (n = 1; 0.8%). The average interval to intervention after patch angioplasty was 4.56 months. CONCLUSIONS: Long-segment bovine pericardial PAM can be performed safely to treat nonmaturing AVFs, with a 92.0% successful maturation rate and patency rates comparable to those for AVFs. PAM should be a consideration for patients with nonmaturing AVFs.

Novel prefabricated bovine pericardial grafts as alternate conduit for septic aortoiliac reconstruction.

OBJECTIVE: Infection of prosthetic aortic grafts represents a serious complication with high morbidity and mortality. Replacement with autologous material is recommended; however, in its absence, biological material should be favored. In the present retrospective cohort study, we evaluated the short- and midterm results with the use of commercially available prefabricated bovine pericardium grafts (BPGs) used for the management of aortic graft infection or aortic reconstructive surgery in the presence of systemic infection. METHODS: We performed a retrospective analysis of patients in whom BPGs had been used for aortic reconstruction at two vascular centers. Prefabricated vascular pericardium grafts were preferred over other biological reconstruction techniques for selected cases. Comorbidities, procedure-related details, perioperative morbidity, clinical outcomes, and mortality were analyzed. RESULTS: From 2014 to 2019, 21 patients had received BPGs at two Austrian vascular centers. Their median age was 63 years (interquartile range [IQR], 55-71 years), the patients were predominantly male (76%), and the median body mass index was 25.3 kg/m2 (IQR, 21.7-27.3 kg/m2). The major comorbidities included arterial hypertension, peripheral artery disease, smoking, and chronic pulmonary disease. The indications for surgery were vascular graft or endograft infection in 62% and aortic reconstruction in the presence of systemic infection in 38%. Three patients (14%) had aortoenteric fistulas. Surgery was technically successful in all cases. The median follow-up was 21.6 months (IQR, 6.0-34.6 months). The 30-day mortality was 9.5%. The 1- and 2-year overall survival was 84% and 75%, respectively. Of the 21 patients, 89% had remained free of recurrent infection. One of the two reinfections had resolved after treatment of the underlying focus. At 2 years, the primary and assisted primary patency rates were 86% and 94%, respectively. No limbs were lost during follow-up. CONCLUSIONS: Prefabricated BPGs represent a promising alternative for the management of aortic graft infections and aortoiliac reconstruction in the presence of systemic infection.

Three-month outcomes of aortic valve reconstruction using collagenous membranes (biosheets) produced by in-body tissue architecture in a goat model: a preliminary study.

BACKGROUND: Autologous pericardium is widely used as a plastic material in intracardiac structures, in the pulmonary artery, and in aortic valve leaflets. For aortic valve reconstruction (AVRec) using the Ozaki procedure, it has produced excellent clinical results over a 10-year period. In-body tissue architecture (iBTA), which is based on the phenomenon of tissue encapsulation of foreign materials, can be used to prepare autologous prosthetic tissues. In this preliminary study, we examined whether biosheets can be used as valve leaflet material for glutaraldehyde-free AVRec by subchronic implantation experiments in goats and evaluated its performance compared with glutaraldehyde-treated autologous pericardium for AVRec. METHODS: Biosheets were prepared by embedding molds for two months into the dorsal subcutaneous spaces of goats. Autogenic biosheets (n = 4) cut into the shape of the valve were then implanted to the aortic valve annulus of four goats for three months without glutaraldehyde treatment. Autologous pericardium (n = 4) was used in four goats as a control. Valve function was observed using echocardiography. RESULTS: All goats survived the three-month study period. With biosheets, the leaflet surfaces were very smooth and, on histology, partially covered with a thin neointima (including endothelial cells). Biosheets were more thoroughly assimilated into the aortic root compared with autologous pericardium. CONCLUSIONS: For the first time, biosheets were used for large animal AVRec. Biosheets could function as leaflets in the aortic position and may have the ability to assimilate into native valves.

The Use of Bovine Pericardial Patches in Vascular Surgery: Where do we Draw the Line in Obtaining Informed Consent?

For a patient undergoing a carotid endarterectomy, induction with propofol, administration of heparin at the time of vessel clamping, use of a bovine pericardial patch for angioplasty, covering the wound with a hydrocolloid dressing and post-operative aspirin administration exposes the patient to animal products at every stage, from the moment they walk through the door. A number of articles have advocated obtaining informed consent when using animal products in healthcare but where should the line be drawn? METHODS: A narrative review of the literature, specifically focussing on secular and religious beliefs about the use of animal products in healthcare. Application of ethical principles and GMC guidance to formulatea discussion with regards to the use of bovine pericardium in vascular surgery. Advanced literature search carried out using Pubmed and Google Scholar databases comparing patch material used forcarotid endarterectomy. RESULTS: Disclosing the use of animal derived constituents in surgery is warranted under Beauchamp and Childress' four principals and highlighted in GMC guidance. Obtaining consent for the use of animalderived constituents at the time of surgery is something that should become a fundamental component of the written consent process and alternatives should be sought where available and practicable. CONCLUSION: This review highlights the evidence available and discusses our current standpoint from both a legal and ethical aspect.