Use of ultrasound debridement as an adjunctive tool for treating infected prosthetic vascular grafts in the lower extremities.

BACKGROUND: To evaluate the role of an ultrasound (US) debridement system to treat conservatively patients with poor medical conditions who presented with infection of a prosthetic vascular graft in the lower extremities. METHODS: Data of all patients who underwent debridement of the grafts and/or surrounding tissue using an ultrasonic generator (Genera, Italia Medica, Milan, Italy) were recorded and retrospectively reviewed. Based on cultures, patients received specific antibiotic therapy. Partial graft removal, sartorius muscle flap rotation, or negative pressure wound treatment (NPWT) was selectively used. Early and late morbidity and mortality and recurrence were analyzed. RESULTS: Thirteen patients (median age, 72 years; range, 57-92 years; 8 men) were treated (12 Szilagyi grade III and 1 grade II infections) with US debridement without removing the graft (8 cases) or with partial excision and "in situ" reconstruction with a silver prosthetic graft (5 cases). Sartorius flap rotation was associated in 6 and NPWT in 1 case. One patient died perioperatively because of pulmonary edema because of sepsis secondary to treatment failure. Estimated freedom from reinfection was 90.9 ± 9% at 6 months and 77.9 ± 14% at 1 and 2 years. Estimated limb survival was 78.7 ± 13% at 6 months, 65.6 ± 16% at 1 year, and 52.5 ± 18% at 2 years. CONCLUSIONS: US debridement proved to be a valuable aid in the treatment of patients with infected grafts and poor medical conditions. Used in conjunction with antibiotics, it allowed us to be more conservative without compromising the chance of success.

Cumulative radiation exposure during thoracic endovascular aneurysm repair and subsequent follow-up.

OBJECTIVES: Thoracic endovascular aneurysm repair (TEVAR) is an appealing alternative to the standard surgical approach, but requires rigorous radiological follow-up. The cumulative radiation exposure (RE) of patients undergoing TEVAR-including pre-operative workup, the procedure and subsequent follow-up computed tomography (CT) imaging-has not previously been investigated. METHODS: From August 2003 to February 2011, 48 patients underwent TEVAR at our institution. Mean age was 66 ± 11 years, with 10 patients (21%) aged <60 years. Forty-one (85%) patients were male; 7 (15%) had urgent/emergent operation; 21 (44%) had undergone previous aortic surgery. Mean aortic diameter was 7.3 ± 2.1 cm. Intra-operative screening time and RE were reviewed, and typical institutional thoracic CT scan RE was calculated (17.8 mSv). Life expectancy of an age- and sex-matched population was estimated to assess the cumulative RE from recurrent CT follow-up. RESULTS: The average screening time was 15.7 ± 11.4 min, with an RE of 11.3 ± 9 mSv. Obese patients had significantly higher RE during TEVAR (Pearson's coefficient = 0.388, P = 0.019). The RE dropped from 14.9 ± 9.4 mSv to 8.6 ± 7.9 mSv (P = 0.033) after a hybrid suite was established. Our institutional TEVAR protocol involves one pre-operative thoracoabdominal CT scan and three follow-up thoracic CT scans for the first year, with a yearly evaluation thereafter. The life expectancy of an age- and sex-matched population was 17 years. A patient adhering to our surveillance protocol would be subjected to an overall exposure of 89 mSv at 1 year and 161 mSv at 5 years, with a projected lifetime RE >350 mSv. CONCLUSIONS: A 2-year RE exceeding the threshold of 100 mSv with a life expectancy >15 years can be estimated to lead to a lifetime risk increase in radiation-induced leukaemia and solid-tumour cancer >2.7%. The risks of cumulative RE especially in younger and/or obese patients must be balanced with the expected morbidity and mortality reduction in TEVAR versus traditional open repair, and the anticipated benefits of recurrent radiographic imaging.