Rupture after endovascular abdominal aortic aneurysm repair: a multicenter study.

A total of 22 patients with ruptured abdominal aortic aneurysms (rAAAs) after previous endovascular aortic repair (EVAR; rAAAevar) were presented to 7 referral hospitals in Greece, between January 2006 and April 2012. Type Ia endoleak and endograft migration were identified in 72.7% and 50%, respectively. Compliance to follow-up protocol prior to rupture was 31.8%. In-hospital mortality was 36.4% (9.1% for those treated with secondary EVAR and 63.6% for those treated with open surgical repair, P = .02). An increase in the proportion of patients with rAAAevar among the total number of patients with rAAAs from 1.3% in 2007 to 18.2% in 2012 (P for trend = .04) was recorded, corresponding to an annual increase of 2.8% (b = 2.84, P = .04). Rupture after EVAR seemed to be a clinical entity encountered with increasing frequency over the past years. Type I endoleak and endograft migration were most frequently observed, whereas compliance to follow-up was low.

Predictors affecting in-hospital mortality of ruptured abdominal aortic aneurysms: a Greek multicenter study.

BACKGROUND: Endovascular aortic repair (EVAR) is being used with increasing frequency for the treatment of ruptured abdominal aortic aneurysms (rAAAs), although conflicting results have been reported concerning perioperative mortality. The aim of our study was to evaluate potential difference in mortality rates between EVAR and open surgical repair (OSR) and identify independent risk factors for in-hospital mortality in rAAAs. This study also aimed to evaluate the Glasgow Aneurysm Score (GAS) in predicting in-hospital mortality. A time-trend analysis of EVAR for ruptured AAAs was also performed. METHODS: Prospectively collected data from 7 public hospitals in Greece concerning rAAA repairs between January 2006 and April 2012 were analyzed. Primary outcome was in-hospital mortality. Multivariate logistic regression analysis was used to identify independent risk factors. The receiver-operator characteristic curve was used to determine the value of the GAS in predicting in-hospital death. Time-trend analysis, depicting annual changes (%), concerning EVAR for ruptured AAAs was also conducted. RESULTS: A total of 418 patients (92.3% men, mean age = 74.3 ± 8.8) with rAAAs were recorded during the study period. Among them, 113 patients (27%) underwent EVAR. Overall in-hospital mortality was 45.2%, whereas in-hospital mortality after EVAR and OSR was 20.4% and 54.3%, respectively (P < 0.001). Multivariate analysis evidenced that hemodynamic instability (P < 0.001), OSR (P < 0.001), age ≥80 years (P < 0.001), coronary artery disease (P < 0.001), and renal insufficiency (P = 0.02) independently increased in-hospital mortality. Area under the curve of GAS was 0.80 (95% confidence interval [CI] = 0.75-0.85, P < 0.001) for OSR and 0.64 (95% CI = 0.51-0.77, P = 0.04) for EVAR. Annual increase of proportion (%) of EVAR for rupture was 5% (P = 0.004). CONCLUSIONS: EVAR is being used with increasing frequency for the treatment of rAAAs and it appears to be associated with lower in-hospital mortality compared with OSR, after adjustment for hemodynamic instability and known atherosclerotic risk factors. Preoperative predictors of in-hospital mortality such as GAS should be probably modified in these patients.

Suprarenal graft fixation in endovascular abdominal aortic aneurysm repair is associated with a decrease in renal function.

INTRODUCTION: Suprarenal endograft fixation is routinely used in the endovascular repair of abdominal aortic aneurysms (EVAR) to enhance proximal endograft attachment but can be associated with an adverse outcome in renal function. This prospective study assessed the effect of suprarenal fixation on serum creatinine concentration and estimated glomerular filtration rate (eGFR), calculated by the Modified Diet in Renal Disease equation, 12 months after elective EVAR. METHODS: Patients undergoing elective EVAR were divided into suprarenal vs infrarenal fixation groups matched for age, sex, smoking, and aneurysm diameter. Serum creatinine and eGFR were measured at baseline, 6, and 12 months. RESULTS: Included were 92 patients (two women) with a mean age of 71 ± 7 years, with 46 in each group. No device-related complications were noted. Serum creatinine did not differ significantly between groups at 6 (P = .24) or 12 (P = .08) months but significantly increased in the suprarenal group at 12 months (1.08 ± 0.36 to 1.16 ± 0.36 mg/dL; P < .001) vs baseline. The eGFR (mL/min/1.73 m(2)) did not differ significantly at baseline between the suprarenal (85 ± 27) and infrarenal (80 ± 28; P = .33) groups or at 6 months (88 ± 29 vs 77 ± 24, respectively; P = .07). At 12 months, the suprarenal group had a lower eGFR (73 ± 23) than the infrarenal group (84 ± 26; P = .027). The eGFR at 12 months showed a significant decrease in the suprarenal (80 ± 28 to 73 ± 23; P < .001) but not in the infrarenal group (85 ± 27 to 84 ± 26; P = .48). The drop in eGFR differed significantly at 12 months in the infrarenal vs the suprarenal (0.82 vs -6.94; P < .001) group. No patient progressed to end-stage renal disease or disclosed a drop in eGFR > 30%. CONCLUSIONS: In contrast to previous studies, this study suggests that suprarenal endograft fixation in elective EVAR is associated with a drop in eGFR at 12 months.

Surgical treatment for large hepatocellular carcinoma: does size matter?

Despite significant progress in the management of hepatocellular carcinoma (HCC), patients with large HCC (defined as >10 cm) continue to present a significant challenge. The goal of this paper is to review the existing literature regarding large HCC, with emphasis on identifying the issues and challenges involved in approaching these tumours surgically. A computerized search was made of the Medline database from January 1992 to December 2010. The MESH heading 'large' or 'huge' in combination with the keyword 'hepatocellular carcinoma' was used. After excluding further studies that identified 'large' HCC as less than 10 cm and/or sequential publications with overlapping patient populations, the search produced a study population of 22 non-duplicated papers, reporting on a total of 5223 patients with HCC tumours >10 cm. Regarding resection for large HCC, the overall 5-year survival in these studies ranged from 25% to 45%, with few outliers on both sides, whereas in most studies, the 5-year disease-free survival ranged between 15% and 35%, with the only exception being studies with patients with single lesions and no cirrhosis showing disease-free survival of 41% and 56%, respectively. Risk factors identified included vascular invasion, cirrhosis, high level of alpha-fetoprotein and the presence of multiple lesions. Finally, liver transplantation, although an attractive concept, did not appear to offer a survival benefit in any of the studies. In conclusion, identifying the risk factors that affect the outcome in patients undergoing surgery for large HCC is critical. The reason is that surgical resection can have excellent outcomes in carefully selected patients.

Anemia is associated with mortality following endovascular repair of abdominal aortic aneurysm.

AIM: The aim of this study was to compare midterm mortality between anemic and nonanemic patients undergoing endovascular repair of abdominal aortic aneurysm and to assess a correlation with markers of inflammation. METHODS: Anemia was defined as hemoglobin <13 (men) and <12 g/dL (women). The impact of anemia and inflammatory markers on mortality was assessed using Kaplan-Meier curves and Cox regression. RESULTS: A total of 224 patients (12 females [5.36%]; age: 69.73 ± 8.72 years) were included; 102 (45.53%) were anemic. Median follow-up was 17 months (interquartile range: 7-25 months). Nine patients died (1.79%; 8 anemic vs 1 nonanemic). Survival was lower for patients with anemia (log-rank, P = .01). White blood cell count and C-reactive protein (CRP) differed significantly (P < .001 and P = .01). Anemia and CRP were associated with decreased survival (Cox regression, P = .01, hazard ratio [HR]: 0.35, 95% confidence interval: 0.14-0.84 and P = .002, HR: 1.18, 95% CI: 1.06-1.31). CONCLUSION: Patients with anemia had decreased survival over the midterm; inflammatory markers were higher among this group.

Helical EndoStaples enhance endograft fixation in an experimental model using human cadaveric aortas.

OBJECTIVE: This study evaluated the contribution of Aptus EndoStaples (Aptus Endosystems, Sunnyvale, Calif) in the proximal fixation of eight endografts used in the endovascular repair of abdominal aortic aneurysms (EVAR). METHODS: Nine human cadaveric aortas were exposed, left in situ, and transected to serve as fixation zones. The Zenith (Cook, Bloomington, Ind), Anaconda (Vascutek, Inchinnan, Scotland, UK), Endurant (Medtronic, Minneapolis, Minn), Excluder (W. L. Gore and Associates, Flagstaff, Ariz), Aptus (Aptus Endosystems), Aorfix (Lombard Medical, Didcot, UK), Talent (Medtronic), and AneuRx (Medtronic) stent grafts were proximally deployed and caudal displacement force (DF) was applied via a force gauge, recording the DF required to dislocate each device ≥20 mm from the infrarenal neck. Measurements were repeated after four and six EndoStaples were applied at the proximal fixation zone, as well as after a Dacron graft was sutured at the proximal neck in standard fashion. Finally, a silicone tube was used as a control fixation zone to test the DF of grafts with EndoStaples in a material that exceeded the integrity of a typical human cadaveric aorta and provided a consistent substrate to examine the differential effect of variable degrees of EndoStaple implantation using zero, two, four, and six EndoStaples. RESULTS: In the cadaveric model, the mean DF required to dislocate the endografts without the application of EndoStaples was 19.73 ± 12.52 N; this increased to 49.72 ± 12.53 N (P < .0001) when four EndoStaples where applied and to 79.77 ± 28.04 N when six EndoStaples were applied (P = .003). The DF necessary to separate the conventionally hand-sutured Dacron graft from the aorta was 56 N. In the silicone tube model, the Aptus endograft without EndoStaples withstood 3.2 N of DF. The DF increased to 39 ± 3 N when two EndoStaples were added, to 71 ± 6 N when four were added, and to 98 ± 5 N when six were added. In eight of the 13 cadaver experiments conducted with four and six EndoStaples, the displacement occurred as a result of complete aortic transection proximal to the fixation site, indicating that aortic tissue integrity was the limiting factor in these experiments. CONCLUSIONS: The fixation of eight different endografts was increased by a mean of 30 N with four Aptus EndoStaples and by a mean of 57 N with six EndoStaples in this model. Endostaples can increase endograft fixation to levels equivalent or superior to that of a hand-sewn anastomosis. The application of six EndoStaples results in aortic tissue failure above the fixation zone, demonstrating fixation strength that exceeds inherent aortic integrity in these cadavers.

Management of traumatic aortic isthmus rupture in case of aberrant right subclavian artery (arteria lusoria).

BACKGROUND: To present an unusual case of blunt aortic injury in a 30-year-old male patient with an aberrant right subclavian artery. METHODS AND RESULTS: Driven by the complicated and challenging nature of the case, we decided to treat the patient by a combined approach-right subclavian artery transposition and endograft implantation at the isthmus level. During the 24-month follow-up (clinical examination, angiogram, computed tomographic scan), we registered no complaints; normal perfusion of the right arm; and adequate sealing of the aortic tear. CONCLUSIONS: We believe that the hybrid management of such trauma is a feasible, effective, and less-invasive option.

Isolated common iliac artery aneurysms: a revised classification to assist endovascular repair.

Isolated common iliac artery aneurysms (CIAAs) are relatively rare; they typically progress asymptomatically and are revealed incidentally, usually after they have acquired significant dimensions. Traditional open reconstruction is associated with high morbidity and mortality rates. Rupture is a common initial manifestation. Endovascular repair has been proposed as a minimally invasive alternative, associated with lower morbidity and mortality rates, even in patients at high surgical risk; some specialists have recently proposed endoluminal repair as the first-choice procedure in suitable anatomies. However, only a few sporadic attempts have been made to define the "suitable" anatomy for endovascular repair. This article proposes a classification of isolated CIAAs and provides endovascular specialists with a guide to deciding which type of repair is feasible and efficacious according to the anatomical configuration of the aneurysm.

Inferior vena cava stent-graft placement to treat endoleak associated with an aortocaval fistula.

PURPOSE: To report a case in which a persistent high-flow type II endoleak after endovascular aneurysm repair (EVAR) of a leaking abdominal aortic aneurysm (AAA) complicated by an aortocaval fistula was repaired with a stent-graft in the inferior vena cava (IVC). CASE REPORT: A 76-year-old man underwent emergent EVAR with an aortomonoiliac device to exclude a leaking 9-cm AAA. The 30-day computed tomography (CT) scan showed 2-mm sac expansion and a type II endoleak arising from a lumbar artery; the outflow vessel was the inferior vena cava (IVC) via a fistula that was not depicted on the non-contrast preoperative CT or the intraoperative angiogram. No intervention was deemed necessary at the time. Six months after EVAR, the AAA had not expanded further, but the fistula between the sac and the IVC was larger in diameter. A tubular stent-graft was implanted in the IVC to seal the defect. No complications have been noted up to 36 months after the IVC stent-graft procedure. CONCLUSION: Aortocaval fistulae should be excluded in the case of persistent type II endoleaks after EVAR for ruptured AAAs. IVC endografting is a minimally invasive alternative to treat such a complication, with promising midterm results in this patient.

New exposure technique for management of giant internal carotid artery aneurysm.

We are presenting a case of giant internal carotid artery aneurysm (ICAA) managed by a new exposure technique. Following double mandibular osteotomy, the exposure of the entire aneurysm was achieved by mandible mobilization. The aneurysm repair was performed by resection and graft interposition. Mandible bone reconstruction was succeeded via mini plate osteosynthesis. No adverse events were noticed during the 24-month follow-up period. The surgical ICAA management is necessary to prevent severe complications. In cases of aneurysm extension to the skull base, double mandibular osteotomy is a safe technique that facilitates aneurysm exposure and control.

Synchronous carotid artery stenting and open heart surgery.

BACKGROUND: The optimal management of the patients requiring cardiac surgery with concomitant severe carotid disease remains a controversy. The traditional approach involves staged or combined carotid endarterectomy and cardiac surgery. This study evaluated the feasibility and safety of angioplasty and stenting for the treatment of carotid stenoses concomitantly to cardiac operations to reduce the risk of perioperative stroke. METHODS: All patients scheduled for cardiac surgery were screened preoperatively by color duplex ultrasonography for carotid disease. Carotid stenoses ≥60% in symptomatic patients and ≥70% in asymptomatic patients were treated using carotid artery stenting (CAS) under local anesthesia immediately before the open heart surgery. Cerebral protection devices were used in all cases. Patients did not receive aspirin or clopidogrel before the procedure. In a prospective, nonrandomized study, we analyzed 90 consecutive patients requiring cardiac surgery with concomitant severe carotid artery disease who underwent one stage CAS and cardiac surgery. RESULTS: Despite the high baseline risk profile, our results were encouraging. Carotid stenting was successful in all patients. No neurologic complications occurred during the carotid stenting procedures. The 30-day death/stroke rate was 2.2% (one death, one contralateral stroke). No myocardial infarction occurred. The carotid restenosis rate was zero during the intermediate-term follow-up. CONCLUSIONS: In our experience, CAS followed immediately by cardiac surgery is safe and represents a reasonable option for selected patients presenting with severe carotid and coronary disease.

Abdominal aortic aneurysm: a review of the genetic basis.

BACKGROUND: Abdominal aortic aneurysm (AAA) is a complex disease with a largely unknown pathophysiological background and a strong genetic component. Various studies have tried to link specific genetic variants with AAA. METHODS: Systematic review of the literature (1947-2009). RESULTS: A total of 249 studies were identified, 89 of which were eventually deemed relevant to this review. Genetic variants (polymorphisms) in a wide variety of genes, most of which encode proteolytic enzymes and inflammatory molecules, have been associated with AAA development and progression. CONCLUSION: The genetic basis of AAA remains unknown, and most results from ''candidate-gene'' association studies are contradictory. Further analyses in appropriately powered studies in large, phenotypically well-characterized populations, including genome-wide association studies, are necessary to elucidate the exact genetic contribution to the pathophysiology of AAA.

Preoperative screening and management of carotid artery disease in patients undergoing cardiac surgery.

BACKGROUND: Carotid artery stenosis (CAS) is a well-known risk factor for perioperative stroke in cardiac surgery. It is unclear whether preoperative carotid screening should be applied to all patients. Carotid intervention concomitantly with cardiac operations is also controversial. Our objective was to identify the prevalence of significant CAS and its related risk factors by applying a protocol of preoperative carotid screening to all patients undergoing cardiac surgery. METHODS: We studied 307 patients who were primarily screened preoperatively by duplex Doppler ultrasonography. Catheter carotid angiography or transcranial Doppler was performed on equivocal cases. Univariate and multivariate analyses were applied across selected parameters to identify risk factors for significant CAS (> 70%). The prevalence of CAS and perioperative stroke rates were determined. RESULTS: Twenty-two patients with severe and 18 with moderate carotid stenosis were identified. Further radiological evaluation with catheter carotid angiography and transcranial Doppler confirmed the presence of significant CAS in 20 patients who underwent carotid stenting or endarterectomy before the open heart surgery. The cardiac surgeon was free to modify the surgical technique according to the preoperative assessment. No patient had major stroke perioperatively, while two minor strokes with complete neurologic recovery have been documented. The history of stroke and the presence of bruit on clinical examination were the only significant predictors of severe carotid disease. CONCLUSION: Careful clinical examination together with detailed previous history taking can identify the majority of patients with CAS. Further data are required for the construction of a scientifically valid policy as a guideline.

Reporting mid- and long-term results of endovascular grafting for abdominal aortic aneurysms using the aortomonoiliac configuration.

PURPOSE: This study evaluated the feasibility, efficacy, and durability of a specific aortomonoiliac endograft for the treatment of abdominal aortic aneurysm (AAA) during a midterm follow-up. METHODS: From January 2002 until November 2008, 106 patients (6 women; mean age, 73.37 +/- 7.39 years) were treated for an AAA using an EndoFit aortomonoiliac graft (LeMaitre Vascular, Burlington, Mass). All procedures were elective. RESULTS: Mean follow-up was 34.9 months (SD, 20.08; range, 2-81 months). Long-term data (follow-up >60 months) were available for nine patients, none of which reported any vascular or procedure related complications. Three of the 106 patients (2.83%) died during early follow-up (<30 days); eight died during late follow-up (7.54%). Endograft infection developed in two patients (1.88%), and an aortoduodenal fistula developed in two (1.88%). Also observed were 15 type II (14.15%) and three type I (2.83%) endoleaks. Femorofemoral bypass thrombosis was detected in two patients (1.88%). CONCLUSION: In this retrospective analysis, the aortomonoiliac configuration for elective AAA repair was proven to be safe and efficacious. Midterm and long-term follow-up results in this series compare well with previously reported results for AAA endografting using both bifurcated and aortomonoiliac endoprostheses.

Endovascular repair of inadvertent subclavian artery perforation during cannulation for dialysis access: case report and review of the literature.

Central venous catheterization is a routine vascular-access procedure; however, it may be associated with life-threatening complications such as arterial puncture, leading to arterial occlusion, embolism, pseudoaneurysm formation, vessel laceration or dissection, haemopneumothorax or massive haemorrhage. We report a case of an accidental subclavian artery perforation with a wide dialysis catheter. A Jostent endovascular covered stent was deployed to seal the deficit. The specific device can easily conform to the anatomical configuration of most peripheral vessels, constituting a good alternative to open repair in cases of accidental vessel puncture.

Failure and success of percutaneous angioplasty in a hypertensive child with bilateral renal artery stenosis.

We describe the clinical course of a 5-year-old girl with severe arterial hypertension that was uncontrollable with antihypertensive medication. Renal angiography revealed bilateral renal artery stenoses. Because percutaneous transluminal renal angioplasty (PTRA) failed to dilate the stenotic lesions, a renal artery bypass grafting in both renal arteries was performed. The patient remained normotensive for 7 months, and after that the arterial pressure increased again. Digital subtraction angiography demonstrated stenosis at the peripheral and central anastomosis of the vein graft that was used for revascularization of the left kidney. PTRA was decided on and successful patency was achieved. The patient has now been normotensive for a period of 5 years.

Minimally invasive endovascular intervention in emergent and urgent thoracic aortic pathologies: single center experience.

INTRODUCTION: We report mid-term results from the endovascular treatment of acute thoracic aortic pathologies in a single center. METHODS: We retrospectively interrogated our clinical database and identified the following patients who were treated for an acute thoracic aortic pathology during a 3-year period (January 2003 to February 2006) with the deployment of a thoracic endograft: 8 male patients diagnosed with a thoracic aortic pseudoaneurysm and/or a thoracic aortic disruption following blunt chest trauma; 1 male patient with a large mobile mural thrombus of the descending thoracic aorta; 1 patient with an aortobronchial fistula; and 8 patients with a symptomatic descending thoracic aortic aneurysm. RESULTS: Complete exclusion of the lesion was achieved in all patients. No procedure-related deaths occurred. Postoperative complications included one case of a distal type 1 endoleak, repaired with re-intervention and deployment of an extension graft, and 1 case of moderate graft kinking without further complications. CONCLUSION: The endovascular treatment of acute thoracic aortic pathologies is technically feasible and safe. Early and intermediate results are promising.

Pharmacotherapy before and after endovascular repair of abdominal aortic aneurysms.

Endovascular (EVAR) abdominal aortic aneurysm (AAA) repair has been established as a successful procedure in the short term and may constitute a viable long-term alternative to open repair (OR). The procedure has been associated with lower operative and mid-term morbidity and mortality compared to OR, but long-term results remain largely controversial. EVAR has also been associated with a significant risk of implant and procedure-related complications, such as graft thrombosis and cardiovascular events, necessitating interventional and pharmaceutical management. Medical management of patients undergoing EVAR is required for several different reasons. Patients with an AAA have an increased risk of cardiovascular death, necessitating treatment to reduce the overall risk for cardiovascular events. Treatment is in-line with the medical management of coronary artery disease including anti-platelet therapy and statins. Anti-platelet therapy is also mandatory to prevent complications such as graft-limb thrombosis and peripheral arterial disease (PAD), which is common in patients with an AAA. Especially in patients with PAD, aspirin, clopidogrel and statins remain the mainstay of medical management. Unfortunately, there is a lack of prospective randomised trials concerning the medical management of patients that have undergone abdominal aortic endo-grafting. We review the current literature on the medical treatment of patients undergoing EVAR, focusing on peri-operative management, anti-platelet agents and statins.

Midterm results of a modified technique for implanting tube grafts during endovascular abdominal aortic aneurysm repair.

PURPOSE: To retrospectively analyze the efficacy and midterm results of endovascular aneurysm repair (EVAR) with a tubular stent-graft using 2 different implantation techniques. METHODS: Between November 2004 and September 2007, 53 patients (49 men; mean age 68.5+/-8.6 years, range 40-80) were treated with the EndoFit tube stent-graft. The majority (45, 85%) were treated using the trombone technique, in which 2 tubular aortoaortic endografts were deployed with 4 to 8 cm of overlap. This subgroup was compared to the 8 patients who received single tube grafts. RESULTS: Technical and procedural success were 100%; perioperative mortality was 0%. Operative results were similar for patients treated with 1 graft versus those treated with the overlapping trombone technique. The overall device-related complication rate was significantly lower for patients treated with the trombone technique (11% versus 75%, p<0.001). Mean follow-up was 24 months (range 6-36). Endoleak type II occurred in 3 (5.7%) cases. Three (5.7%) patients died, 1 from an aortoduodenal fistula secondary to a proximal type I endoleak and 2 from acute myocardial infarction. CONCLUSION: The tubular EndoFit device appears both safe and effective in terms of midterm clinical outcome, especially when the trombone technique is utilized. It compares favorably with previously reported EVAR results.

Aortoduodenal fistulas after endovascular stent-graft repair of abdominal aortic aneurysms: single-center experience and review of the literature.

PURPOSE: To report a single-center experience with aortoduodenal fistula (ADF) after successful endovascular aneurysm repair (EVAR) of an infrarenal abdominal aortic aneurysm (AAA). METHODS: Five patients (all men; mean age 68.4 years, range 60-75) developed an ADF between 18 days to 1 year after successful EVAR using 3 types of commercially available endografts: 1 bifurcated Anaconda, 1 unibody Powerlink, and 3 EndoFit stent-grafts in a tubular (n=1) or aortomonoiliac configuration (n=2). The internal iliac artery was not occluded in any of the cases. RESULTS: Hematemesis and diffuse abdominal pain constituted the main symptoms leading to the diagnosis of ADF, which was confirmed on computed tomography. Infection was the etiology of the ADF in 3 patients; all underwent emergency surgical exploration, but 1 died in hospital; the other 2 have survived from 1 to 3 years after an emergency procedure. The other 2 ADFs developed in patients with large type I endoleaks; 1 patient died before surgery could be performed and the other one 18 hours after laparotomy. All stent-grafts were removed; none displayed any defects. CONCLUSION: ADF is a rare but dangerous complication of EVAR. The sequela may be primarily attributed to graft infection, as seen in this series. However, the exact pathogenesis of the pathology remains largely unknown. Prompt diagnosis and intervention are crucial to avoid a fatal outcome.