Ann Vasc Dis Vol. 9, No. 1; 2016; pp 70–72 ©2016 Annals of Vascular Diseases
Online January 27, 2016 doi:10.3400/avd.cr.15-00122
Case Report
Aortoiliac Artery Reconstruction Using Bilateral Reversed Superficial Femoral Veins for an Infected Abdominal Aortic Aneurysm Satoshi Ohki, MD, Hanako Hirai, MD, Kiyomitsu Yasuhara, MD, Kyohei Hatori, MD, Takao Miki, MD, and Tamiyuki Obayashi, MD
Surgical treatment of an infected abdominal aortic aneurysm (IAAA) is difficult and the ideal graft material is a subject of debate. A 60-year-old man with untreated diabetes mellitus was referred to our hospital presenting with fever and left lower abdominal pain. The patient was diagnosed with an IAAA by blood culture and computed tomography. We treated the patient surgically for the IAAA using bilateral reversed superficial femoral veins which were shaped into a bifurcated graft. No signs of recurrent infection or aneurysmal dilation were observed for 3 years after the procedure.
Keywords: infected abdominal aortic aneurysm, superficial femoral vein
Introduction Infected abdominal aortic aneurysm (IAAA) is a potentially lethal condition that develops following the expansion of a local infection or septic embolism. Surgical treatment of an IAAA is difficult and the optimal graft material is a subject of debate. Superficial femoral vein (SFV) grafts resist gram-positive and negative infections.1) However, the size of the unilateral of SFV is usually smaller than the adult male infrarenal abdominal aorta. Small graft has possibility of obstruction,2) therefore, we performed an IAAA repair by using bilateral reversed SFVs shaped into a bifurcated graft.
Case Report A 60-year-old man with untreated diabetes mellitus was referred to our hospital presenting with fever and left lower Department of Cardiovascular Surgery, Isesaki Municipal Hospital, Isesaki, Gunma, Japan Received: November 20, 2015; Accepted: January 10, 2016 Corresponding author: Satoshi Ohki, MD. Department of Cardiovascular Surgery, Isesaki Municipal Hospital, 12-1 Tsunatori-honmachi, Isesaki, Gunma 372-0817, Japan Tel: +81-270-25-5022, Fax: +81-270-25-5023 E-mail: [email protected]
70
abdominal pain. The patient’s hemoglobin A1c was 12.1%. The white blood cell (WBC) count was 14200/µl and C-reactive protein 12.6 mg/dl indicating severe inflammatory changes. Blood culture revealed positive for Salmonella O9. Computed tomography (CT) scans revealed a small sacciform infrarenal abdominal aortic aneurysm (AAA) (Figs. 1A, 1B). We initiated intravenous antibiotic treatment (aminobenzyl penicillin, 2 g. daily for 6 h). Seven days later, a second abdominal CT was performed, revealing rapid sacciform infrarenal AAA and left common iliac artery expansion (Figs. 1C, 1D). We diagnosed it as an IAAA and selected in situ aortoiliac artery reconstruction using the SFVs, because the patient had untreated diabetes mellitus and severe purulent infection. After antibiotic agents were administered intravenously for 2 weeks preoperatively, WBC count (8100/µl) and C-reactive protein (0.81 mg/dl) indicated almost normal range. Blood culture was negative for Salmonella O9. We repaired the IAAA using bilateral reversed SFVs shaped into a bifurcated graft. The SFV harvesting technique has been described in detail previously.1) The proximal end of the reversed SFV graft was 1.0 to 1.5 cm in diameter (Fig. 2A). This is relatively small compared to the size of the adult male infrarenal abdominal aorta. Small graft is at a risk of obstruction,2) therefore, we used bilateral reversed SFVs which were cut longitudinally at both proximal ends about 4 to 5 cm and were sutured sideby-side using 5-0 monofilament sutures. The proximal end was about 2.0 to 2.5 cm in diameter (Fig. 2B). Debridement and lavage of the aneurysm sac and infected clot were performed, thereafter, we repaired the IAAA by using a bifurcated graft. The handling of graft was good. After reconstruction of the abdominal aorta, we performed omentopexy. Culture from abdominal aneurysmal tissue was positive for Salmonella O9. The patient experienced bilateral transient leg edema postoperatively, but recovered well quickly. Antibiotic agents (aminobenzyl penicillin, 2 g. daily for 6 h) were administered for 4 weeks postoperatively until the patient demonstrated normal leukocyte and C-reactive protein levels. Thereafter, oral antibiotic (levofloxacin, 500 mg orally once per day) treatment was continued for Annals of Vascular Diseases Vol. 9, No. 1 (2016)
Bilateral Reversed SFVs for IAAA (A)
(B)
(C)
(D)
Fig. 1 (A) Preoperative computed tomography (CT) image. Axial view showing a small sacciform infrarenal abdominal aortic aneurysm (white arrow) and (B) left common iliac artery aneurysm (white arrow). (C) Second preoperative CT image obtained 7 days later. Axial view showing rapid sacciform infrarenal abdominal aortic aneurysm expansion (white arrow) and (D) left common iliac artery expansion (white arrow).
(A)
(B)
Fig. 2 (A) The proximal end of a superficial femoral vein (SFV) graft is 1.0 to 1.5 cm in diameter and approximately 25 cm in length. (B) The bilateral reversed SFVs were cut longitudinally at both proximal ends to about 4 to 5 cm and were sutured side-by-side using 5-0 monofilament sutures.
6 months. No signs of recurrent infection and no aneurysmal dilation of the SFV graft were observed for 3 years after the procedure (Fig. 3).
(A)
(B)
Fig. 3 (A) Preoperative three-dimensional imaging of the left common iliac artery showing pseudoaneurysmal changes (white arrow). (B) Postoperative CT showing no size mismatch between each proximal and distal anastomosis (white arrow) and no aneurysmal dilation of the SFV graft for 3 years after surgery. CT: computed tomography; SFV: superficial femoral vein
Discussion Surgical treatment for an IAAA is difficult and the optimal timing, surgical techniques, and graft material remain subjects of debate. The surgical approaches include either in situ graft replacement or extra-anatomic bypass. In situ graft replacement was traditionally contraindicated in patients with severe purulent infection, Staphylococcus aureus Annals of Vascular Diseases Vol. 9, No. 1 (2016)
infection and Salmonella species infection, because of the risk of early graft infection. However, extra-anatomical bypass is associated with rupture at the aortic stump and has a low long-term graft patency rate.3) Excellent results have been reported for in situ replacement using allografts. However, cryopreserved allografts are often not available in Japan 71
Ohki S, et al.
because of the generally limited availability of allografts in the region.4) The patient had untreated diabetes mellitus and blood cultures were positive for Salmonella O9. Therefore, we chose to perform in situ aortoiliac artery reconstruction using bilateral reversed SFVs. We avoided using prosthetic grafts such as expanded polytetrafluoroethylene and rifampicin-soaked prosthetic graft. The SFV has been utilized as a conduit for vascular reconstruction since 1981.5) Clagett et al. reported that aortoiliac artery reconstruction using SFVs provides excellent long-term patency.1) However, SFV grafts as replacements for the infrarenal abdominal aorta do not perform well because of their small size relative to the abdominal aorta. Furthermore, SFV grafts are reportedly associated with slight decreases in the lumen size over time.1) We suspected that the small graft size might introduce the possibility of obstruction, and chose to use bilateral reversed SFVs shaped into a bifurcated graft instead. When SFVs are harvested, number of points should be addressed. Preoperative duplex ultrasound examination is necessary to assess the size and patency of SFVs and the greater saphenous veins.1) Coburn et al. reported that deep vein harvesting below the knee is associated with venous stasis edema, occasionally resulting in phlegmasia and limb loss.6) However, multiple studies have demonstrated a low incidence of venous morbidity, which in most cases resolves over time.1,2) In the present case, the patient experienced bilateral transient leg edema, but recovered well quickly. No signs of recurrent infection or aneurysmal dilation were observed for 3 years after the surgery. We believe that this technique can not only provide lower risks of postoperative reinfection, but also provide graft patency for long duration.
Conclusion We presented a case of successful surgical treatment for an IAAA using bilateral SFVs shaped into a bifurcated
72
graft. The size of the graft was suitable for replacing the abdominal aorta. We believe that this procedure is a valid surgical treatment of an IAAA, especially the patient with severe diabetes mellitus and purulent infection.
Disclosure Statement The authors have no conflicts of interest to declare.
Author Contributions SO drafted the article. TO helped write the paper. All authors participated in critical review and the revision of the articles. All authors gave the final approval of the article. All authors have accountability for all aspects of the work.
References 1) Clagett GP, Valentine RJ, Hagino RT. Autogenous aortoiliac/ femoral reconstruction from superficial femoral-popliteal veins: feasibility and durability. J Vasc Surg 1997; 25: 25566; discussion 267-70. 2) Valentine RJ, Hansen ME, Myers SI, et al. The influence of sex and aortic size on late patency after aortofemoral revascularization in young adults. J Vasc Surg 1995; 21: 296-305; discussion 305-6. 3) Hsu RB, Chen RJ, Wang SS, et al. Infected aortic aneurysms: clinical outcome and risk factor analysis. J Vasc Surg 2004; 40: 30-5. 4) Yamanaka K, Omura A, Nomura Y, et al. Surgical strategy for aorta-related infection. Eur J Cardiothorac Surg 2014; 46: 974-80; discussion 980. 5) Schulman ML, Badhey MR. Deep veins of the leg as femoropopliteal bypass grafts. Arch Surg 1981; 116: 1141-5. 6) Coburn M, Ashworth C, Francis W, et al. Venous stasis complications of the use of the superficial femoral and popliteal veins for lower extremity bypass. J Vasc Surg 1993; 17: 1005-8; discussion 1008-9.
Annals of Vascular Diseases Vol. 9, No. 1 (2016)
Online January 27, 2016 doi:10.3400/avd.cr.15-00122
Case Report
Aortoiliac Artery Reconstruction Using Bilateral Reversed Superficial Femoral Veins for an Infected Abdominal Aortic Aneurysm Satoshi Ohki, MD, Hanako Hirai, MD, Kiyomitsu Yasuhara, MD, Kyohei Hatori, MD, Takao Miki, MD, and Tamiyuki Obayashi, MD
Surgical treatment of an infected abdominal aortic aneurysm (IAAA) is difficult and the ideal graft material is a subject of debate. A 60-year-old man with untreated diabetes mellitus was referred to our hospital presenting with fever and left lower abdominal pain. The patient was diagnosed with an IAAA by blood culture and computed tomography. We treated the patient surgically for the IAAA using bilateral reversed superficial femoral veins which were shaped into a bifurcated graft. No signs of recurrent infection or aneurysmal dilation were observed for 3 years after the procedure.
Keywords: infected abdominal aortic aneurysm, superficial femoral vein
Introduction Infected abdominal aortic aneurysm (IAAA) is a potentially lethal condition that develops following the expansion of a local infection or septic embolism. Surgical treatment of an IAAA is difficult and the optimal graft material is a subject of debate. Superficial femoral vein (SFV) grafts resist gram-positive and negative infections.1) However, the size of the unilateral of SFV is usually smaller than the adult male infrarenal abdominal aorta. Small graft has possibility of obstruction,2) therefore, we performed an IAAA repair by using bilateral reversed SFVs shaped into a bifurcated graft.
Case Report A 60-year-old man with untreated diabetes mellitus was referred to our hospital presenting with fever and left lower Department of Cardiovascular Surgery, Isesaki Municipal Hospital, Isesaki, Gunma, Japan Received: November 20, 2015; Accepted: January 10, 2016 Corresponding author: Satoshi Ohki, MD. Department of Cardiovascular Surgery, Isesaki Municipal Hospital, 12-1 Tsunatori-honmachi, Isesaki, Gunma 372-0817, Japan Tel: +81-270-25-5022, Fax: +81-270-25-5023 E-mail: [email protected]
70
abdominal pain. The patient’s hemoglobin A1c was 12.1%. The white blood cell (WBC) count was 14200/µl and C-reactive protein 12.6 mg/dl indicating severe inflammatory changes. Blood culture revealed positive for Salmonella O9. Computed tomography (CT) scans revealed a small sacciform infrarenal abdominal aortic aneurysm (AAA) (Figs. 1A, 1B). We initiated intravenous antibiotic treatment (aminobenzyl penicillin, 2 g. daily for 6 h). Seven days later, a second abdominal CT was performed, revealing rapid sacciform infrarenal AAA and left common iliac artery expansion (Figs. 1C, 1D). We diagnosed it as an IAAA and selected in situ aortoiliac artery reconstruction using the SFVs, because the patient had untreated diabetes mellitus and severe purulent infection. After antibiotic agents were administered intravenously for 2 weeks preoperatively, WBC count (8100/µl) and C-reactive protein (0.81 mg/dl) indicated almost normal range. Blood culture was negative for Salmonella O9. We repaired the IAAA using bilateral reversed SFVs shaped into a bifurcated graft. The SFV harvesting technique has been described in detail previously.1) The proximal end of the reversed SFV graft was 1.0 to 1.5 cm in diameter (Fig. 2A). This is relatively small compared to the size of the adult male infrarenal abdominal aorta. Small graft is at a risk of obstruction,2) therefore, we used bilateral reversed SFVs which were cut longitudinally at both proximal ends about 4 to 5 cm and were sutured sideby-side using 5-0 monofilament sutures. The proximal end was about 2.0 to 2.5 cm in diameter (Fig. 2B). Debridement and lavage of the aneurysm sac and infected clot were performed, thereafter, we repaired the IAAA by using a bifurcated graft. The handling of graft was good. After reconstruction of the abdominal aorta, we performed omentopexy. Culture from abdominal aneurysmal tissue was positive for Salmonella O9. The patient experienced bilateral transient leg edema postoperatively, but recovered well quickly. Antibiotic agents (aminobenzyl penicillin, 2 g. daily for 6 h) were administered for 4 weeks postoperatively until the patient demonstrated normal leukocyte and C-reactive protein levels. Thereafter, oral antibiotic (levofloxacin, 500 mg orally once per day) treatment was continued for Annals of Vascular Diseases Vol. 9, No. 1 (2016)
Bilateral Reversed SFVs for IAAA (A)
(B)
(C)
(D)
Fig. 1 (A) Preoperative computed tomography (CT) image. Axial view showing a small sacciform infrarenal abdominal aortic aneurysm (white arrow) and (B) left common iliac artery aneurysm (white arrow). (C) Second preoperative CT image obtained 7 days later. Axial view showing rapid sacciform infrarenal abdominal aortic aneurysm expansion (white arrow) and (D) left common iliac artery expansion (white arrow).
(A)
(B)
Fig. 2 (A) The proximal end of a superficial femoral vein (SFV) graft is 1.0 to 1.5 cm in diameter and approximately 25 cm in length. (B) The bilateral reversed SFVs were cut longitudinally at both proximal ends to about 4 to 5 cm and were sutured side-by-side using 5-0 monofilament sutures.
6 months. No signs of recurrent infection and no aneurysmal dilation of the SFV graft were observed for 3 years after the procedure (Fig. 3).
(A)
(B)
Fig. 3 (A) Preoperative three-dimensional imaging of the left common iliac artery showing pseudoaneurysmal changes (white arrow). (B) Postoperative CT showing no size mismatch between each proximal and distal anastomosis (white arrow) and no aneurysmal dilation of the SFV graft for 3 years after surgery. CT: computed tomography; SFV: superficial femoral vein
Discussion Surgical treatment for an IAAA is difficult and the optimal timing, surgical techniques, and graft material remain subjects of debate. The surgical approaches include either in situ graft replacement or extra-anatomic bypass. In situ graft replacement was traditionally contraindicated in patients with severe purulent infection, Staphylococcus aureus Annals of Vascular Diseases Vol. 9, No. 1 (2016)
infection and Salmonella species infection, because of the risk of early graft infection. However, extra-anatomical bypass is associated with rupture at the aortic stump and has a low long-term graft patency rate.3) Excellent results have been reported for in situ replacement using allografts. However, cryopreserved allografts are often not available in Japan 71
Ohki S, et al.
because of the generally limited availability of allografts in the region.4) The patient had untreated diabetes mellitus and blood cultures were positive for Salmonella O9. Therefore, we chose to perform in situ aortoiliac artery reconstruction using bilateral reversed SFVs. We avoided using prosthetic grafts such as expanded polytetrafluoroethylene and rifampicin-soaked prosthetic graft. The SFV has been utilized as a conduit for vascular reconstruction since 1981.5) Clagett et al. reported that aortoiliac artery reconstruction using SFVs provides excellent long-term patency.1) However, SFV grafts as replacements for the infrarenal abdominal aorta do not perform well because of their small size relative to the abdominal aorta. Furthermore, SFV grafts are reportedly associated with slight decreases in the lumen size over time.1) We suspected that the small graft size might introduce the possibility of obstruction, and chose to use bilateral reversed SFVs shaped into a bifurcated graft instead. When SFVs are harvested, number of points should be addressed. Preoperative duplex ultrasound examination is necessary to assess the size and patency of SFVs and the greater saphenous veins.1) Coburn et al. reported that deep vein harvesting below the knee is associated with venous stasis edema, occasionally resulting in phlegmasia and limb loss.6) However, multiple studies have demonstrated a low incidence of venous morbidity, which in most cases resolves over time.1,2) In the present case, the patient experienced bilateral transient leg edema, but recovered well quickly. No signs of recurrent infection or aneurysmal dilation were observed for 3 years after the surgery. We believe that this technique can not only provide lower risks of postoperative reinfection, but also provide graft patency for long duration.
Conclusion We presented a case of successful surgical treatment for an IAAA using bilateral SFVs shaped into a bifurcated
72
graft. The size of the graft was suitable for replacing the abdominal aorta. We believe that this procedure is a valid surgical treatment of an IAAA, especially the patient with severe diabetes mellitus and purulent infection.
Disclosure Statement The authors have no conflicts of interest to declare.
Author Contributions SO drafted the article. TO helped write the paper. All authors participated in critical review and the revision of the articles. All authors gave the final approval of the article. All authors have accountability for all aspects of the work.
References 1) Clagett GP, Valentine RJ, Hagino RT. Autogenous aortoiliac/ femoral reconstruction from superficial femoral-popliteal veins: feasibility and durability. J Vasc Surg 1997; 25: 25566; discussion 267-70. 2) Valentine RJ, Hansen ME, Myers SI, et al. The influence of sex and aortic size on late patency after aortofemoral revascularization in young adults. J Vasc Surg 1995; 21: 296-305; discussion 305-6. 3) Hsu RB, Chen RJ, Wang SS, et al. Infected aortic aneurysms: clinical outcome and risk factor analysis. J Vasc Surg 2004; 40: 30-5. 4) Yamanaka K, Omura A, Nomura Y, et al. Surgical strategy for aorta-related infection. Eur J Cardiothorac Surg 2014; 46: 974-80; discussion 980. 5) Schulman ML, Badhey MR. Deep veins of the leg as femoropopliteal bypass grafts. Arch Surg 1981; 116: 1141-5. 6) Coburn M, Ashworth C, Francis W, et al. Venous stasis complications of the use of the superficial femoral and popliteal veins for lower extremity bypass. J Vasc Surg 1993; 17: 1005-8; discussion 1008-9.
Annals of Vascular Diseases Vol. 9, No. 1 (2016)
