Treatment of a Delayed Type IIIb Endoleak 20 Years Post EVAR With Inverted Contralateral Limb Custom-Made Device: A Case Report.

PURPOSE: Type III endoleak can be difficult to distinguish from Type I endoleak. Depending on the stent graft anatomy, the use of standard bifurcated endografts may not be technically feasible, and patients may have to be subject to an aorto-uni-iliac repair with femoral-femoral bypass or open surgery. CASE REPORT: We report a case of an 86-year-old male who had a Type IIIb endoleak 20 years post EVAR which was characterized on angiography to be from a hole close to the bifurcation limb origin. The initial Talent (Medtronic, Santa Rosa, California) device had a 50 mm main body common trunk, which was not amenable to treatment with standard devices. He was successfully treated with a custom-made device with an inverted contralateral limb. CONCLUSIONS: Our case highlights the need for lifelong surveillance post EVAR as endoleak may present decades post initial EVAR. It also demonstrates that many Type III endoleak which were otherwise deemed unsuitable for treatment with standard devices may potentially be treatable with custom-made device (CMD). This solution preserves a percutaneous option in a now older person which avoids surgical bypass. Further studies are required to establish the durability of this treatment and survey for recurrence.

Decreasing trends in reintervention and readmission after endovascular aneurysm repair in a multiregional implant registry.

OBJECTIVE: As endovascular aortic aneurysm repair (EVAR) matures into its third decade, measures such as long-term reintervention and readmission have become a focus of quality improvement efforts. Within a large United States integrated health care system, we describe time trends in the rates of long-term reinterventions utilization measures. METHODS: Data from a United States multiregional EVAR registry was used to perform a descriptive study of 3891 adults who underwent conventional infrarenal EVAR for infrarenal abdominal aortic aneurysm between 2010 and 2019. Three-year follow-up was 96.7%. Outcomes included 1-, 3-, and 5-year graft revision (defined as a procedure involving placement of a new endograft component), secondary interventions (defined as a procedure necessary for maintenance of EVAR integrity [eg, coil embolization and balloon angioplasty/stenting]), conversion to open, interventions for type II endoleaks alone, and 90-day readmission. Crude cause-specific reintervention probabilities were calculated by operative year using the Aalen-Johansen estimator, with death as a competing risk and December 31, 2020 as the study end date. RESULTS: Excluding interventions for type II endoleak alone, 1-year secondary intervention incidence decreased from 5.9% for EVARs in 2010 to 2.0% in 2019 (P < .001) and 3-year incidence decreased from 7.2% to 3.6% from 2010 to 2017 (P = .03). The 3-year incidences of graft revision (mean incidence, 3.4%) and conversion to open remained fairly stable (mean incidence, 0.6%) over time. The 3-year incidence of interventions for type II endoleak alone also decreased from 3.4% in 2010 to 0.7% in 2017 (P = .01). Ninety-day readmission rates decreased from 19.3% for index EVAR in 2010 to 9.2% in 2019 (P = .03). CONCLUSIONS: Comprehensive data from a multiregional health care system demonstrates decreasing long-term secondary intervention and readmission rates over time in patients undergoing EVAR. These trends are not explained by evolving management of type II endoleaks and suggest improving graft durability, patient selection, or surgical technique. Further study is needed to define implant and anatomic predictors of different types of long-term reintervention.

Safety and efficacy of endovascular implantation of a portal vein stent combined with iodine-125 seed-strips followed by transcatheter arterial chemoembolization with sorafenib for the treatment of hepatocellular carcinoma with portal vein tumor thrombosis.

OBJECTIVE: To assess the safety and efficacy of endovascular implantation of a portal vein stent combined with iodine-125 seed-strips followed by transcatheter arterial chemoembolization with sorafenib (PVS-125I-TACE-S) for the treatment of hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT). METHODS: Between January 2015 and July 2017, 18 patients with PVTT caused by HCC that were treated with PVS-125I-TACE-S were reviewed. The technical success, complications, changes in liver function from baseline values due to subsequent endovascular implantation of a portal vein stent combined with iodine-125 seed-strips (PVS-125I), time-to-tumor progression (TTP) and overall survival (OS) were observed. RESULTS: The technical success rate was 100%. Adverse events (AEs) were managed successfully, with no occurrence of procedure-related deaths. Liver function test values after PVS-125I were not significantly different than baseline values (P＞0.05). The median TTP was 7.0 months (range: 4.2-9.9 months). In Vp3 PVTT, the TTP was 9.7 months (range: 8.8-10.5 months), and in Vp4 PVTT, the TTP was 4.2 months (range: 2.8-5.6 months). The median OS was 10.0 months (range: 7.0-13.1 months). In Vp3 PVTT, OS was 11.9 months (range: 9.2-14.5 months), and in Vp4 PVTT, OS was 7.2 months (range: 3.8-10.7 months). CONCLUSIONS: PVS-125I-TACE-S is safe for patients with HCC with PVTT and may extend the TTP and survival of patients with Vp4 PVTT. ADVANCES IN KNOWLEDGE: PVS implantation promptly restored flow in the obstructed portal vein, which can reduce the risk of hepatic failure and upper gastrointestinal bleeding. Implantation of iodine-125 seed-strips may directly expose the portal tumor thrombus to radiation and kill cancer cells. Their combined use with TACE-S has a strong scientific rationale.

Open Conversion after Aortic Endograft Infection Caused by Colistin-Resistant, Carbapenemase-Producing Klebsiella pneumoniae.

A 62-year-old man presented with fever, abdominal pain, and malaise 13 months after emergency endovascular aortic repair. Computed tomographic angiograms showed a periprosthetic fluid and gas collection, so infection was diagnosed. Open conversion was performed, involving endograft explantation and in situ aortic reconstruction. Cultures and the explanted prosthesis were positive for carbapenemase-producing Klebsiella pneumoniae, resistant to colistin. Because of the sparse data on endograft infections caused by this pathogen, we placed the patient on an empiric double-carbapenem regimen for 4 weeks. Symptomatic recovery occurred after 21 days. On the 30th day, we deployed a stent to treat a new pseudoaneurysm. Three years later, the patient had no signs of persistent or recurrent infection. We think that this is the first report of aortic endograft infection caused by colistin-resistant, carbapenemase-producing K. pneumoniae.

Aortic graft infection and mycotic aneurysm with Streptococcus equi zooepidemicus: two cases with favorable outcome of antibiotic treatment.

Infections with Streptococcus equi zooepidemicus are rare and are associated with contact with animals or animal products. There are very few reports about infected vascular grafts or aneurysms with this etiology. We present two patients. The first is a 77-year-old man with an infected bifurcated graft four years after an open operation for an abdominal aortic aneurysm (AAA). The second is a 72-year-old man with a symptomatic mycotic AAA, treated with endovascular aneurysm repair. Both received prolonged treatment with bactericidal antibiotics and responded well. Follow-up time at present is 5.5 years for the first, and 4.5 years for the second, patient.

Antibiotic-impregnated beads for the treatment of aortic graft infection.

Infection of a prosthetic graft after replacement of the ascending aorta is an uncommon but life-threatening complication of surgery. We report the use of antibiotic-impregnated calcium sulfate beads in a patient with ascending aortic graft infection to provide localized, high-dose therapy to the infected region. Perigraft placement of antibiotic beads provides an alternative method for the treatment of aortic graft infection.

Laparoscopic diagnosis and treatment of aortic vascular prosthetic graft infections in a porcine model.

OBJECTIVES: To study the feasibility and efficacy of experimental laparoscopy in the diagnosis of aortic graft infection in pigs. MATERIAL AND METHODS: Eight pigs had an aortic tube graft implanted and inoculated with either 5 x 10(4) or 10(6) CFU of Staphylococcus aureus ATCC 29213. Laparoscopy was performed after a median of 20 days with debridement and sampling for bacterial culture. Thereafter, the grafts were locally soaked in rifampicin and postoperatively, the pigs received rifampicin and ciprofloxacin orally for two weeks and were then sacrificed. RESULTS: All pigs developed graft infection. One pig died from severe clostridial septicaemia before laparoscopy could be performed. The remaining pigs had all samples for bacterial culture taken by laparoscopy from the inflamed tissue. The temperature dropped significantly after laparoscopy, and no macroscopic signs of infection presented at autopsy. However, only culture from one pig was without S. aureus at autopsy. CONCLUSIONS: Laparoscopy is a potential diagnostic tool for aortic graft infection and also affords the opportunity to carry out bacteriological sampling and local antibiotic treatment. The efficacy of laparoscopic treatment needs further evaluation.

Successful treatment of infected vascular prosthetic grafts in the groin using conservative therapy with povidone-iodine solution.

Four cases of infected vascular prosthetic graft in the groin successfully treated with povidone-iodine solution using a conservative approach are described here. In all patients the same technique was used. After complete debridement, the prosthetic graft in the groin was completely exposed. The wound was cleansed with hydrogen peroxide and then dressed with gauze soaked in 1:10 sterile water-diluted povidone-iodine solution. The dressings were changed twice a day. The patients were supplemented by systemic therapy of an appropriate antibiotic. All patients were observed in the intensive care unit. In all patients this treatment method led to control of infection and healing of the wound. Thus, it was not necessary to remove the prosthetic graft and patients were spared a major surgical intervention. At follow-up, the prosthetic grafts remain patent without any signs of recurrence of infection.

Treatment of a primary type IA endoleak with a liquid embolic system under conditions of aortic occlusion.

We present the case of a primary type IA endoleak after deployment of a bifurcated Ancure endograft (Guidant Endovascular Solutions, Menlo Park, Calif) to treat a 9-cm abdominal aortic aneurysm with a short angulated neck. The endoleak was treated unsuccessfully with repeat balloon angioplasty, placement of a Palmaz aortic stent (Cordis Endovascular, Miami, Fla), and deployment of an AneuRx aortic extender cuff (Medtronic AneuRx, Santa Rosa, Calif). The endoleak then was sealed with injection of n-butyl cyanoacrylate into the aneurysm sac at the site of the leak with occlusion of aortic flow. We suggest the use of this liquid embolic agent be considered as an adjunct to control primary type IA endoleaks when other forms of therapy have failed.

Efficacy of quinupristin-dalfopristin in preventing vascular graft infection due to Staphylococcus epidermidis with intermediate resistance to glycopeptides.

A rat model was used to investigate the efficacy of quinupristin-dalfopristin (Q-D) in the prevention of vascular prosthetic graft infection due to methicillin-resistant Staphylococcus epidermidis with intermediate resistance to glycopeptides. The in vitro activity of the compound was compared to that of vancomycin by MIC determination and time-kill study. Moreover, the efficacy of collagen-sealed Q-D-soaked Dacron was evaluated in a rat model of graft infection. Graft infections were established in the subcutaneous tissue of the backs of 120 adult male Wistar rats. The in vivo study included a control group, one contaminated group that did not receive any antibiotic prophylaxis, two contaminated groups that received grafts soaked with 10 and 100 micro g of Q-D per ml, respectively, and two contaminated groups that received grafts soaked with 10 and 100 micro g of vancomycin per ml, respectively. Rats that received Dacron grafts soaked with 100 micro g of Q-D per ml showed no evidence of infection (<10 CFU/ml). In contrast, for rats that received Dacron grafts soaked with 10 micro g of Q-D per ml and Dacron grafts soaked with 10 or 100 micro g of vancomycin per ml, the quantitative graft cultures demonstrated 2.2 x 10(2) +/- 1.3 x 10(2), 2.2 x 10(6) +/- 1.9 x 10(5), and 5.6 x 10(2) +/- 0.3 x 10(2) CFU/ml, respectively. Taken together the results of the study demonstrate that the use of Dacron grafts soaked with Q-D can result in significant bacterial growth inhibition and show that this compound is potentially valuable for prevention of vascular prosthetic graft infection.

Prophylaxis of hemodialysis graft thrombosis with fish oil: double-blind, randomized, prospective trial.

Diets enriched with fish oil may favorably affect the vascular perturbations underlying synthetic graft thrombosis. Therefore, these studies were designed to test the hypothesis that diets enriched with fish oil would decrease the incidence of thrombosis in newly constructed polytetrafluorethylene grafts. A double-blind, randomized trial was conducted. Twenty-four patients were randomized to receive 4000 mg of fish oil or 4000 mg of control oil. Both preparations were enriched with antioxidants and deodorized with peppermint. Patients began therapy within 2 wk after graft placement and were monitored for 12 mo or until thrombosis developed. With a permuted-block randomization schedule, 12 patients received fish oil and 12 patients received control oil. The primary patency rates at 365 d were 14.9% for the control group and 75.6% for the fish oil-treated group. Survival analysis revealed a significant difference between fish oil-treated and untreated patients (P < 0.03, Mantel-Cox test), with a power of 90%. Moreover, analysis of covariables, including age of > or =50 yr, gender, race, body weight, diabetes mellitus, bleeding times, and lipid profiles, indicated that this effect occurred principally as a result of fish oil administration. Importantly, fish oil treatment also decreased venous outflow resistance and systemic BP, compared with control values. Fish oils possess unique biologic properties that favorably affect the incidence of polytetrafluorethylene graft thrombosis, and they thus represent a potential treatment strategy for the prevention of access thrombosis.

Polycationic peptides as prophylactic agents against methicillin-susceptible or methicillin-resistant Staphylococcus epidermidis vascular graft infection.

Several polycationic peptides isolated from animals, plants, and bacterial species possess a broad spectrum of antimicrobial activity. A rat model was used to investigate the efficacies of two peptides, ranalexin and buforin II, in the prevention of vascular prosthetic graft infections. The effect of peptide-soaked collagen-sealed Dacron was compared to that of rifampin-soaked collagen-sealed Dacron in the rat model of graft infection caused by methicillin-susceptible rifampin-susceptible Staphylococcus epidermidis and methicillin-resistant rifampin-susceptible S. epidermidis. Graft infections were established in the back subcutaneous tissue of 240 adult male Wistar rats by implantation of 1-cm(2) Dacron prostheses, followed by topical inoculation with 2 x 10(7) CFU of S. epidermidis. The study included a control group (no graft contamination), two contaminated groups that did not receive any antibiotic prophylaxis, two contaminated groups to which perioperative intraperitoneal cefazolin prophylaxis (30 mg/kg of body weight) was administered, six contaminated groups that received a peptide- or rifampin-soaked graft, and six contaminated groups that received a peptide- or rifampin-soaked graft and perioperative intraperitoneal cefazolin prophylaxis (30 mg/kg). The grafts were sterilely removed 7 days after implantation, and the infection was evaluated by using sonication and quantitative agar culture. Overall, the efficacies of the polycationic peptides against the methicillin-susceptible and methicillin-resistant strains were not significantly different from that of rifampin. Nevertheless, the combinations of ranalexin- and buforin II-coated grafts with cefazolin treatment demonstrated efficacies significantly higher than that of the combination of rifampin-coated grafts and cefazolin treatment against the methicillin-resistant strain.

Improved results with conventional management of infrarenal aortic infection.

PURPOSE: Interest in alternative methods, such as autogenous vein grafts and aortic allografts, for the management of infrarenal aortic infection (IRAI) has been stimulated by the historically disappointing results with conventional surgical management. Recently, there have been dramatic improvements in the results of axillofemoral bypass grafting (AXFB) followed by excision of the IRAI that have gone relatively unrecognized. The purpose of this report is the presentation of modern-day results in the treatment of IRAI with conventional surgical methods. METHODS: From January 1, 1983, through June 30, 1998, patients with IRAI underwent treatment with AXFB and complete excision of the IRAI. The patients were followed for survival, limb salvage, and AXFB graft patency. The results were tabulated with life-table methods. RESULTS: During the 15-year study period, 60 patients (51 men, nine women; mean age, 68 years) underwent treatment for IRAI (50 graft infections, including 16 graft-enteric fistulae, and 10 primary aortic infections). The mean follow-up period was 41 months. The perioperative mortality rate was 13% (12% for graft infection, and 20% for primary infection). The overall 2-year and 5-year survival rates were 67% and 47%, respectively. The limb salvage rates at 2 and 5 years were 93% and 82%, respectively. The 5-year primary AXFB graft patency rate was 73%. CONCLUSION: These results show an improvement with the conventional management of IRAI equal or superior to those results reported with alternative methods, including femoral vein grafts or aortic allografts. These results should be regarded as the modern standard with which alternative therapies can be compared.

Preincubation of Dacron grafts with recombinant tissue factor pathway inhibitor decreases their thrombogenicity in vivo.

BACKGROUND: We have previously shown that preincubation of whole blood clots with recombinants tissue factor pathway inhibitor (rTFPI) attenuates clot-associated procoagulant activity assessed ex vivo. This study was undertaken to determine whether a single local application of rTFPI induces similar attenuation of the procoagulant activity on preclotted Dacron grafts implanted in an artery in vivo. METHODS: Dacron grafts (4 mm x 4 cm long) were preclotted in porcine blood and incubated with either rTFPI (5 mg/ml) or arginine-phosphate buffer for 15 minutes. Grafts were implanted end-to-end in the femoral arteries of 10 pigs, with one rTFPI-treated and one buffer-treated graft implanted in each animal. Animals did not undergo anticoagulation either before or after graft implantation. Radiolabeled porcine fibrinogen was injected intravenously, and the grafts underwent perfusion for 1 hour. A subgroup of animals (n = 7) also had infusion of radiolabeled autologous platelets at the time of administration of radiolabeled fibrinogen. RESULTS: Fibrin(ogen) deposition was decreased in rTFPI-treated grafts by 36% +/- 7% (mean +/- SEM) compared with buffer-treated grafts (p = 0.001). Platelet deposition was also reduced in the rTFPI-treated grafts by 31% +/- 15%, although the reduction did not reach statistical significance (p = 0.10). The extent of rTFPI-mediated attenuation of fibrin(ogen) versus platelet deposition varied independently among animals. CONCLUSIONS: Clot-directed anticoagulant effects of rTFPI appear to be useful for substantially decreasing the thrombogenicity of Dacron grafts immediately after their implantation. Chronic studies to determine whether the decreases in thrombogenicity result in improved long-term graft patency appear warranted.

Prevention of graft infection by bonding of gentamycin to Dacron prostheses.

To increase the efficacy of perioperative antibiotic prophylaxis in vascular surgery an experimental study including topical application of the gentamicin derivative EMD 46/217 and fibrin sealant as antibiotic carrier to Dacron prostheses was initiated. In vitro treatment of Dacron with gentamicin and fibrin was followed by constant antibiotic release for 3 weeks. In a subsequent animal study Dacron grafts were implanted in the aorta of 10 pigs after direct contamination with Staphylococcus aureus solution. One graft was pretreated with the antibiotic/fibrin compound, a second with the antibiotic alone. Grafts 3 (no pretreatment) and 4 (fibrin alone) served as controls. After 1 week the grafts and their corresponding implantation sites were excised for measurement of antibiotic content and for culture. The antibiotic content of grafts with the antibiotic/fibrin compound was 25.0 +/- 7.2 micrograms/gm wet weight, whereas Dacron pretreated with the antibiotic alone contained no measurable drug amounts except for one specimen (0.5 microgram/gm) (antibiotic/fibrin vs antibiotic, p less than .0005). The corresponding implantation sites to antibiotic/fibrin grafts contained 1.07 +/- 0.54 microgram/gm antibiotic, whereas in only 2/10 implantation sites of antibiotic grafts low antibiotic levels were found (0.05 and 0.2 microgram/gm) (antibiotic/fibrin vs antibiotic, p less than 0.005). All control grafts and 9/10 antibiotic grafts were infected. By contrast, only five were contaminated, and 5 of 10 remained sterile after culture (antibiotic/fibrin vs antibiotic, p less than 0.05). This finding correlates with the antibiotic content in the Dacron. It is concluded that pretreatment of prosthetic Dacron grafts with the antibiotic/fibrin compound results in binding of sufficient amounts of antibiotic for at least 1 week.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term patency of regenerated neoaortic wall following the implant of a fully biodegradable polyurethane prosthesis: experimental lipid diet model in pigs.

The degradation of a polyurethane vascular prosthesis, the time course and characteristics of tissue ingrowth and prosthesis replacement, and the incidence of thrombosis have been investigated in 50 young pigs. A 6-7 cm long cone-shaped prosthesis was implanted in the infrarenal aorta of 50 young growing pigs which were sacrificed at intervals from 60 to 365 days. Ten animals were controls, 25 were given aspirin 10 mg/kg of body weight/day, and 15 were fed with cod liver oil. Aortography, done at 30, 60, and 90 days, showed 100% of implants were thrombosed in the surviving controls, 55% of the aspirin group had patent grafts, and 100% of animals in the lipid diet group had patent grafts. At final graft retrieval, the aspirin group showed only three patencies, while in the lipid diet group seven out of nine animals were patent. The laboratory and morphological studies indicated that all patent prostheses were lined with tissue that resembled the intima of native aorta with a layer of smooth muscle cells which appeared complete at 180 days. From these data we conclude that the biodegradable polyurethane vascular prosthesis is reliable for experimental implants in a pig model. The lipid-rich diet of polyunsaturated fatty acids potentiates long-term patency, perhaps by preventing platelet aggregation and thrombosis, and allowing the growth of a neoendothelium and neomedia within the lumen of the prosthesis, which slowly degrade towards fatty tissue and form neoadventitia.

Prevention of platelet aggregation by dietary polyunsaturated fatty acids in the biodegradable polyurethane vascular prosthesis: an experimental model in pigs.

A 6-7 cm long degradable polyurethane vascular prosthesis was implanted in the infrarenal aorta of 25 young growing pigs, sacrificed from day 30 to 365 to study the processes of degradation and tissue growth, the characteristics of prosthetic substitutes and the incidence of thrombosis. Ten animals were used as controls and 15 were fed with cod liver oil (25 ml twice daily). Aortography performed at day 30, 60 and 90 showed 100% thrombosed implants in the controls, while in the lipid diet fed animals there was 100% patency. At graft retrieval, there were 7 patent grafts out of 9 in the cod liver oil fed animals. Laboratory tests indicated that the lipid diet rich in n-3 polyunsaturated fatty acids induces significant modifications of lipid metabolism preventing platelet aggregation. These data correlate well with findings of the morphological studies showing that all patent prostheses are lined with tissues similar to the endothelium of the native aorta with a mid layer made of circular and longitudinal smooth muscle cells well differentiated at day 180. These data show that the essential polyunsaturated fatty acid rich diet is able to prevent thrombosis of the biodegradable polyurethane vascular prosthesis. The combination of a synthetic material and the lipid diet experimental model, makes it possible to assess the long-term tissue-synthetic material interaction and the process of tissue growth.