RESUMO
OBJECTIVE: Abdominal aortic graft and endograft infections (AGIs) are rare complications following aortic surgery. Radical surgery (RS) with resection of the infected graft and reconstruction with extra-anatomical bypass or in situ reconstruction is the preferred therapy. For patients unfit for RS, a semi-conservative (SC), graft preserving strategy is possible. This paper aimed to compare survival and infection outcomes between RS and SC treatment for AGI in a nationwide cohort. METHODS: Patients with abdominal AGI related surgery in Sweden between January 1995 and May 2017 were identified. The Management of Aortic Graft Infection Collaboration (MAGIC) criteria were used for the definition of AGI. Multivariable regression was performed to identify factors associated with mortality. RESULTS: One hundred and sixty-nine patients with surgically treated abdominal AGI were identified, comprising 43 SC (14 endografts; 53% with a graft enteric fistula [GEF] in total) and 126 RS (26 endografts; 50% with a GEF in total). The SC cohort was older and had a higher frequency of cardiac comorbidities. There was a non-significant trend towards lower Kaplan-Meier estimated five year survival for SC vs. RS (30.2% vs. 48.4%; p = .066). A non-significant trend was identified towards worse Kaplan-Meier estimated five year survival for SC patients with a GEF vs. without a GEF (21.7% vs. 40.1%; p = .097). There were significantly more recurrent graft infections comparing SC with RS (45.4% vs. 19.3%; p < .001). In a Cox regression model adjusting for confounders, there was no difference in five year survival comparing SC vs. RS (HR 1.0, 95% CI 0.6 - 1.5). CONCLUSION: In this national AGI cohort, there was no mortality difference comparing SC and RS for AGI when adjusting for comorbidities. Presence of GEF probably negatively impacts survival outcomes of SC patients. Rates of recurrent infection remain high for SC treated patients.
Assuntos
Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Procedimentos Endovasculares , Infecções Relacionadas à Prótese , Humanos , Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Tratamento Conservador/efeitos adversos , Fatores de Risco , Estudos Retrospectivos , Procedimentos Endovasculares/efeitos adversos , Complicações Pós-Operatórias/etiologia , Infecções Relacionadas à Prótese/cirurgia , Infecções Relacionadas à Prótese/etiologia , Resultado do Tratamento , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/complicaçõesRESUMO
OBJECTIVE: Abdominal aortic graft and endograft infection (AGI) is primarily treated by resection of the infected graft and restoration of distal perfusion through extra-anatomic bypass (EAB) or in situ reconstruction/repair (ISR). The aim of this study was to compare these surgical strategies in a nationwide multicentre retrospective cohort study. METHODS: The Swedish Vascular Registry (Swedvasc) was used to identify surgically treated abdominal AGIs in Sweden between January 1995 and May 2017. The primary aim was to compare short and long term survival, as well as complications for EAB and ISR. RESULTS: Some 126 radically surgically treated AGI patients were identified - 102 graft infections and 24 endograft infections - treated by EAB: 71 and ISR: 55 (23 neo-aorto-iliac systems, NAISs). No differences in early 30 day (EAB 81.7% vs. ISR 76.4%, p = .46), or long term five year survival (48.2% vs. 49.9%, p = .87) were identified. There was no survival difference comparing NAIS to other ISR strategies. The frequency of recurrent graft infection during follow up was similar: EAB 20.3% vs. ISR 17.0% (p = .56). Survival and re-infection rates of the new conduit did not differ between NAIS and other ISR strategies. Age ≥ 75 years (odds ratio [OR] 4.0, confidence interval [CI] 1.1 - 14.8), coronary artery disease (OR 4.2, CI 1.2 - 15.1) and post-operative circulatory complications (OR 5.2, CI 1.2 - 22.5) were associated with early death. Prolonged antimicrobial therapy (> 3 months) was associated with reduced long term mortality (HR 0.3, CI 0.1 - 0.9). CONCLUSION: In this nationwide multicentre study comparing outcomes of radically treated AGI, no differences in survival or re-infection rate could be identified comparing EAB and ISR.
Assuntos
Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Infecções Relacionadas à Prótese/cirurgia , Idoso , Aorta Abdominal/diagnóstico por imagem , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/diagnóstico por imagem , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/mortalidade , Sistema de Registros , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Suécia , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: We investigated in a porcine model whether measuring both the flow distal to an anastomosis and the graft transit time flow (TTF) gives a more accurate picture of the true blood flow in the left anterior descending artery (LAD) than graft TTF measurement alone. METHODS: We performed off-pump coronary artery bypass grafting (CABG)-left internal mammary artery (LIMA) to the LAD-on 5 Yorkshire-Landrace pigs. Snares were placed both proximal and distal to the anastomosis. Flow was measured with ultrasound and TTF. This was carried out on the LIMA and at 2 locations on the LAD. Measurements were performed at the following times: baseline, during proximal snaring, after proximal snare loosening, during distal snaring, after distal snare loosening, and during both proximal and distal snaring. RESULTS: During distal snaring, the TTF dropped (P = .047), and the pulsatile index (PI) increased (P = .025), while the ultrasound flow in the LAD dropped (P = .002). During proximal and distal snaring, the ultrasound flow dropped (P = .005), but the TTF value did not change significantly, compared with baseline. CONCLUSION: A high flow and a low PI were seen in the graft, both proximal and distal to the anastomosis, despite a fully occluded LAD. This result suggests that graft TTF measurement alone is not sufficient when performing CABG, and measurement of flow distal to the anastomosis is also necessary to determine the true blood flow in the LAD.