Improving Survival and Limb Salvage in Patients with Aortic Graft Infection Richard A. Yeager, MD, Gregory L. Moneta, MD, Lloyd M. Taylor, Jr., MD, E. John Harris, Jr., MO, Donald B. McConnell, MD, John M. Porter, MD, Portland,Oregon
A 15-year experience with 38 aortic graft infections, including 15 patients with graft enteric fistulas, is reviewed in order to analyze modern-day surgical results utilizing extra-anatomic bypass and aortic graft excision. Perioperative mortality was 14% during the most recent 7-year interval, which was a notable improvement compared with the earlier time interval (p = 0 . 0 6 ) . Extended follow-up of the perioperative survivors demonstrated a 77% cumulative 5-year survival and a 76% cumulative 5-year limb Salvage rate. Subsequent axillofemoral graft infection oecurred in 22% of survivors and resulted in a significantly higher amputation rate compared with those patients with no axillofemoral graft infection (p < 0 . 0 0 1 ) . The results suggest good perioperative and long-term survival in patients with aortic graft infection, with excellent limb salvage if subsequent axillofemorai graft infection can be avoided.
patients (34 men, 4 women; mean age: 66 years) with aortic graft infection were identified. Thirteen patients (34%) had the aortic graft inserted at one of the two reporting institutions, while 25 patients (66%) had their original aortic operation at another hospital. Medical records were reviewed with respect to method of diagnosis, surgical management of the aortic graft infection, graft culture results and subsequent axillofemoral graft infection, amputation rate, and late renal dysfunction, Follow-up survival and limb salvage data were obtained from the patient's medical record, by telephone contact, and from review of death certificates and available autopsy reports. Cumulative survival and limb salvage were calculated utilizing life-table analysis. Resuits were tabulated for both the entire study group as well as for the perioperative survivors. Perioperative mortality was defined as either death within 1 month of operation or death during the initial hospitalization. Apparent differences in mortality rates and limb salvage rates were analyzed for significance using a two-tailed Fisher's exact test [7].
RESULTS Fifteen patients (39%) had a graft-enteric fistula and 23 patients (61%) had aortic perigraft infection without bowel involvement. The mean interval from time of aortic graft insertion to diagnosis of graft infection was 6 years bdominal aortic prosthetic graft infection is a dif- (range: 2 weeks to 18 years). The original aortic anastoficult surgical problem historically associated with a mosis was end-to-end in 25 patients (9 for occlusive disdisappointing outcome. Bunt's [1,2] review reported an ease and 16 for aneurysmal disease) and end-to-side in 13 overall operative mortality in the treatment of aortic pros- patients. thetic graft infection approximating 50%. Only recently Of the 38 patients, 20 (53%) presented with fever have some investigators reported improved operative and/or leukocytosis, 17 (45%) with an inguinal wound mortalities of 10% to 25% [3-6]. Although the surgical infection or draining sinus, 14 (37%) with overt gastroinmanagement of this problem is improving, questions re- testinal bleeding, and 6 (16%) with a history of significant main as to the duration and quality Of life for operative weight loss. Of the 15 patients with a graft-enteric fistula, survivors. This report confirms the lower operative mor- 13 presented with overt gastrointestinal bleeding (metality of aortic graft infection with modern-day surgical lena, hematochezia, or hemetemesis). Seven of these pamanagement and documents extended survival and limb tients underwent esophagogastroduodenoscopy. Only one salvage in a high percentage of operative survivors. of these examinations was diagnostic for graft-enteric fistula. Computed tomographic (CT) scanning was perPATIENTS AND METHODS formed preoperatively in 16 patients (42%). CT scanning Computerized vascular registry data and operative demonstrated perigraft fluid in eight patients, perigraft logbooks were reviewed for the period January 1975 fluid and gas in two additional patients, and perigraft through October 1989. During this 15-year interval, 38 inflammation without fluid or gas in two patients. CT From the Divisionof Vascular Surgery,Departmentof Surgery,Ore- scanning gave false-negative results for infection in 4 of gon HealthSciencesUniversityand PortlandVeteransAffairsMedical 16 (25%) patients. Indium-labeled White blood cell scans demonstrated increased uptake within a portion of the Center, Portland,Oregon. Requests for reprints shouldbe addressedto RichardA. Yeager, aortic bifurcation graft in five of the six patients studied. MD, PortlandVeteransAffairsMedicalCenter,SurgicalService112P, Contrast sinography was utilized twice and was diagnosPO Box 1034,Portland,Oregon97207. Presentedat the 76th AnnualMeetingof the North PacificSurgi- tic for graft infection both times. Magnetic resonance cal Association.Victoria.BritishColumbia,Canada,November10-11. imaging demonstrated perigraft fluid in the one patient in which it was utilized. 1989.
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THE AMERICAN JOURNAL OF SURGERY VOLUME159 MAY 1990
AORTIC GRAFTINFECTION
TABLE I
Perloperatlve Mortality and Method of Management of Aortic Graft Infecllon (n = 38) Perioperative
Perioperative
Type of Management
No. of Patients
% of Total
Deaths (n)
Mortality (%)
Axillofemoral bypass followed by aortic graft excision Aortic graft excision followed by axlllofemoral
24
63
5
21
9
24
3
33
3
5
2
67
2
5
0
0
38
100
10
26
bypass Aortic graft excision with autogenous reconstruction Aortic graft excision with in situ prosthetic grafting Total
Methods of surgical management of the infected aortic graft and early results are listed in Table I. Prosthetic axillofemoral grafting through clean tissue planes was utilized in 31 (82%) of the 38 patients. Perioperative death occurred in 10 of the 38 patients (26%), giving an overall cumulative 5-year survival of 52%. Primary causes of perioperative death included myocardial infarction in four patients, sepsis and multisystem failure in four patients, irreversible hemorrhagic shock in one patient, and aortic stump duodenal fistula in one patient. There were 5 (22%) perioperative deaths among the 23 patients with aortic perigraft infection and 5 (33%) perioperative deaths among the 15 patients with graft-enteric fistula. Seven deaths (44%) occurred among the 16 patients managed during the earliest 8-year period of review (1975 to 1982), while only three deaths (14%) occurred among the 22 patients managed during the most recent 7year interval (1983 to 1989) (p = 0.06). Aortic graft cultures were positive in 32 patients (84%), negative in 2 patients, and not obtained in 4 patients. Graft cultures from the patients with graft-enteric fistula generally grew mixed flora, including gram-positive cocci and gram-negative enteric organisms. The culture results for the 23 patients with aortic perigraft infection are listed in Table II. The 28 operative survivors had a mean follow-up of 3.7 years (range: 1 to 125 months). There have been 9 late deaths (32%), 2 patients lost to follow-up, and 17 patients alive with ongoing follow-up. The causes of late death were cardiac diseases in three patients, cancer in two patients, stroke in one patient, aortic stump disruption in one patient, diverticulitis in one patient, and an unknown cause in one patient. For the 28 perioperative survivors, cumulative 5-year survival was 77%. Major lower extremity amputations occurred in six survivors (21%) during follow-up. The overall amputation rate was 18% (10 limbs of 55 limbs at risk). The cumulative 5-year limb salvage rate for perioperative survivors was 76%. Subsequent axillofemoral prosthetic graft infection occurred in 5 of the 23 operative survivors (22%) with axillofemoral grafts. Two of 16 (13%) polytetrafluoroeth-
TABLE II Aortic Perlgraff Infection Graft Culture Results ( n = 2 2 ) * Organism
No. of Casest
% of Cases
Staphylococcus epidermidis S. aureus Streptococcus Escherlchia col~ Enterococcus Pseudornonas Bacteroldes Klebsiella Candlda Diphtheroids No growth
12 5 5 2 1 1 1 1 i 1 2
55.0 23.0 23.0 9.0 4.5 4.5 4.5 4.5 4.5 4.5 9.0
* Cultures not obtainable in one case, Multiple organisms reported in eight cases.
ylene (PTFE) grafts and 3 of 7 (43%) Dacron grafts became infected (p = 0.142). Twenty-four percent (4 of 17) of axillofemoral prosthetic grafts placed prior to aortic graft removal developed infection compared with 17% (1 of 6) of such grafts inserted after aortic graft excision (p = 1). Interval from initial placement of axillofemoral graft to diagnosis of axillofemoral graft infection was 2 weeks in three patients, 1 month in one patient, and 16 months in one patient. In three of five patients, Staphylococcus epidermidis was the causative organism for both the aortic graft infection and the subsequent axillofemoral graft infection. Axillofemoral graft infection was managed by graft excision in all five patients, with three patients additionally undergoing rerouting of a new axillofemoral graft. The 5 patients with prosthetic axillofemoral graft infection had a significantly higher amputation rate (7 amputations of 10 limbs at risk) compared with the 18 patients without axillofemoral graft infection (1 amputation of 35 limbs at risk) (p
A 15-year experience with 38 aortic graft infections, including 15 patients with graft enteric fistulas, is reviewed in order to analyze modern-day surgical results utilizing extra-anatomic bypass and aortic graft excision. Perioperative mortality was 14% during the most recent 7-year interval, which was a notable improvement compared with the earlier time interval (p = 0 . 0 6 ) . Extended follow-up of the perioperative survivors demonstrated a 77% cumulative 5-year survival and a 76% cumulative 5-year limb Salvage rate. Subsequent axillofemoral graft infection oecurred in 22% of survivors and resulted in a significantly higher amputation rate compared with those patients with no axillofemoral graft infection (p < 0 . 0 0 1 ) . The results suggest good perioperative and long-term survival in patients with aortic graft infection, with excellent limb salvage if subsequent axillofemorai graft infection can be avoided.
patients (34 men, 4 women; mean age: 66 years) with aortic graft infection were identified. Thirteen patients (34%) had the aortic graft inserted at one of the two reporting institutions, while 25 patients (66%) had their original aortic operation at another hospital. Medical records were reviewed with respect to method of diagnosis, surgical management of the aortic graft infection, graft culture results and subsequent axillofemoral graft infection, amputation rate, and late renal dysfunction, Follow-up survival and limb salvage data were obtained from the patient's medical record, by telephone contact, and from review of death certificates and available autopsy reports. Cumulative survival and limb salvage were calculated utilizing life-table analysis. Resuits were tabulated for both the entire study group as well as for the perioperative survivors. Perioperative mortality was defined as either death within 1 month of operation or death during the initial hospitalization. Apparent differences in mortality rates and limb salvage rates were analyzed for significance using a two-tailed Fisher's exact test [7].
RESULTS Fifteen patients (39%) had a graft-enteric fistula and 23 patients (61%) had aortic perigraft infection without bowel involvement. The mean interval from time of aortic graft insertion to diagnosis of graft infection was 6 years bdominal aortic prosthetic graft infection is a dif- (range: 2 weeks to 18 years). The original aortic anastoficult surgical problem historically associated with a mosis was end-to-end in 25 patients (9 for occlusive disdisappointing outcome. Bunt's [1,2] review reported an ease and 16 for aneurysmal disease) and end-to-side in 13 overall operative mortality in the treatment of aortic pros- patients. thetic graft infection approximating 50%. Only recently Of the 38 patients, 20 (53%) presented with fever have some investigators reported improved operative and/or leukocytosis, 17 (45%) with an inguinal wound mortalities of 10% to 25% [3-6]. Although the surgical infection or draining sinus, 14 (37%) with overt gastroinmanagement of this problem is improving, questions re- testinal bleeding, and 6 (16%) with a history of significant main as to the duration and quality Of life for operative weight loss. Of the 15 patients with a graft-enteric fistula, survivors. This report confirms the lower operative mor- 13 presented with overt gastrointestinal bleeding (metality of aortic graft infection with modern-day surgical lena, hematochezia, or hemetemesis). Seven of these pamanagement and documents extended survival and limb tients underwent esophagogastroduodenoscopy. Only one salvage in a high percentage of operative survivors. of these examinations was diagnostic for graft-enteric fistula. Computed tomographic (CT) scanning was perPATIENTS AND METHODS formed preoperatively in 16 patients (42%). CT scanning Computerized vascular registry data and operative demonstrated perigraft fluid in eight patients, perigraft logbooks were reviewed for the period January 1975 fluid and gas in two additional patients, and perigraft through October 1989. During this 15-year interval, 38 inflammation without fluid or gas in two patients. CT From the Divisionof Vascular Surgery,Departmentof Surgery,Ore- scanning gave false-negative results for infection in 4 of gon HealthSciencesUniversityand PortlandVeteransAffairsMedical 16 (25%) patients. Indium-labeled White blood cell scans demonstrated increased uptake within a portion of the Center, Portland,Oregon. Requests for reprints shouldbe addressedto RichardA. Yeager, aortic bifurcation graft in five of the six patients studied. MD, PortlandVeteransAffairsMedicalCenter,SurgicalService112P, Contrast sinography was utilized twice and was diagnosPO Box 1034,Portland,Oregon97207. Presentedat the 76th AnnualMeetingof the North PacificSurgi- tic for graft infection both times. Magnetic resonance cal Association.Victoria.BritishColumbia,Canada,November10-11. imaging demonstrated perigraft fluid in the one patient in which it was utilized. 1989.
A
466
THE AMERICAN JOURNAL OF SURGERY VOLUME159 MAY 1990
AORTIC GRAFTINFECTION
TABLE I
Perloperatlve Mortality and Method of Management of Aortic Graft Infecllon (n = 38) Perioperative
Perioperative
Type of Management
No. of Patients
% of Total
Deaths (n)
Mortality (%)
Axillofemoral bypass followed by aortic graft excision Aortic graft excision followed by axlllofemoral
24
63
5
21
9
24
3
33
3
5
2
67
2
5
0
0
38
100
10
26
bypass Aortic graft excision with autogenous reconstruction Aortic graft excision with in situ prosthetic grafting Total
Methods of surgical management of the infected aortic graft and early results are listed in Table I. Prosthetic axillofemoral grafting through clean tissue planes was utilized in 31 (82%) of the 38 patients. Perioperative death occurred in 10 of the 38 patients (26%), giving an overall cumulative 5-year survival of 52%. Primary causes of perioperative death included myocardial infarction in four patients, sepsis and multisystem failure in four patients, irreversible hemorrhagic shock in one patient, and aortic stump duodenal fistula in one patient. There were 5 (22%) perioperative deaths among the 23 patients with aortic perigraft infection and 5 (33%) perioperative deaths among the 15 patients with graft-enteric fistula. Seven deaths (44%) occurred among the 16 patients managed during the earliest 8-year period of review (1975 to 1982), while only three deaths (14%) occurred among the 22 patients managed during the most recent 7year interval (1983 to 1989) (p = 0.06). Aortic graft cultures were positive in 32 patients (84%), negative in 2 patients, and not obtained in 4 patients. Graft cultures from the patients with graft-enteric fistula generally grew mixed flora, including gram-positive cocci and gram-negative enteric organisms. The culture results for the 23 patients with aortic perigraft infection are listed in Table II. The 28 operative survivors had a mean follow-up of 3.7 years (range: 1 to 125 months). There have been 9 late deaths (32%), 2 patients lost to follow-up, and 17 patients alive with ongoing follow-up. The causes of late death were cardiac diseases in three patients, cancer in two patients, stroke in one patient, aortic stump disruption in one patient, diverticulitis in one patient, and an unknown cause in one patient. For the 28 perioperative survivors, cumulative 5-year survival was 77%. Major lower extremity amputations occurred in six survivors (21%) during follow-up. The overall amputation rate was 18% (10 limbs of 55 limbs at risk). The cumulative 5-year limb salvage rate for perioperative survivors was 76%. Subsequent axillofemoral prosthetic graft infection occurred in 5 of the 23 operative survivors (22%) with axillofemoral grafts. Two of 16 (13%) polytetrafluoroeth-
TABLE II Aortic Perlgraff Infection Graft Culture Results ( n = 2 2 ) * Organism
No. of Casest
% of Cases
Staphylococcus epidermidis S. aureus Streptococcus Escherlchia col~ Enterococcus Pseudornonas Bacteroldes Klebsiella Candlda Diphtheroids No growth
12 5 5 2 1 1 1 1 i 1 2
55.0 23.0 23.0 9.0 4.5 4.5 4.5 4.5 4.5 4.5 9.0
* Cultures not obtainable in one case, Multiple organisms reported in eight cases.
ylene (PTFE) grafts and 3 of 7 (43%) Dacron grafts became infected (p = 0.142). Twenty-four percent (4 of 17) of axillofemoral prosthetic grafts placed prior to aortic graft removal developed infection compared with 17% (1 of 6) of such grafts inserted after aortic graft excision (p = 1). Interval from initial placement of axillofemoral graft to diagnosis of axillofemoral graft infection was 2 weeks in three patients, 1 month in one patient, and 16 months in one patient. In three of five patients, Staphylococcus epidermidis was the causative organism for both the aortic graft infection and the subsequent axillofemoral graft infection. Axillofemoral graft infection was managed by graft excision in all five patients, with three patients additionally undergoing rerouting of a new axillofemoral graft. The 5 patients with prosthetic axillofemoral graft infection had a significantly higher amputation rate (7 amputations of 10 limbs at risk) compared with the 18 patients without axillofemoral graft infection (1 amputation of 35 limbs at risk) (p
