the utility of the femoral vein as a vascular conduit
TRANSCRIPT
![Page 1: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/1.jpg)
![Page 2: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/2.jpg)
![Page 3: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/3.jpg)
University Hospital
Parkland Hospital
![Page 4: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/4.jpg)
Contemporary Management of
Aortic Graft Infections
R. James Valentine, MD
Division of Vascular and Endovascular Surgery
UT Southwestern Medical Center
Dallas, Texas
![Page 5: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/5.jpg)
Outline
• Presentation and diagnosis
• Treatment options and outcomes
• Role for endovascular therapy
![Page 6: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/6.jpg)
Aortic Grafts
• Widespread use
– since 1954
• Excellent durability
• Inert material
– No rejection
– Susceptible to infection
![Page 7: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/7.jpg)
Aortic Graft Infections
• Affect 2-3% of all
prosthetic grafts
• Higher in groin
incisions
• Higher in emergency
cases
![Page 8: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/8.jpg)
Infection Sources
![Page 9: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/9.jpg)
INTRAOPERATIVE CONTAMINATION
Patient Factors
• Skin edge
• Redo operations
• Lymphatics
• Groin incision
![Page 10: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/10.jpg)
Efficacy of prophylactic antibiotics in vascular surgery: An arterial wall
microbiologic and pharmacokinetic perspective S. Lalka, J Malone, D Fisher Jr., V. Bernhard, D Sullivan, D Stoeckelmann, R.Bergstrom
• N=29 with groin incisions
• Preoperative antibiotics
• Samples for culture
– Serum
– Subcutaneous fat
– Atheroma
– Arterial wall
JVS 1989; 10: 501-9
![Page 11: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/11.jpg)
Efficacy of prophylactic antibiotics in vascular surgery: An arterial wall
microbiologic and pharmacokinetic perspective S. Lalka, J Malone, D Fisher Jr., V. Bernhard, D Sullivan, D Stoeckelmann, R.Bergstrom
• 41% had positive arterial cultures
• 70% S. epidermidis
– Half slime producers
JVS 1989; 10: 501-9
![Page 12: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/12.jpg)
• Remote infection – UTI
– Pneumonia
• Distal source
INTRAOPERATIVE CONTAMINATION
Patient Factors
![Page 13: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/13.jpg)
• Laminated thrombus
– 15-20% + cultures
– 10% s. epidermidis
• Lymphatics
INTRAOPERATIVE CONTAMINATION
Patient Factors
![Page 14: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/14.jpg)
INTRAOPERATIVE CONTAMINATION
Surgeon Factors
• Hole in glove
• Break in sterile
technique
• Concomitant procedures – Cholecystectomy
– Appendectomy
![Page 15: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/15.jpg)
INTRAOPERATIVE CONTAMINATION
Surgeon Factors
• N = 40 graft procedures
(most aortic)
• Preoperative antibiotics
• Randomised to glove change
• Cultured grafts and gloves
Zdanowski et al, Eur J Vasc Endovasc Surg 1999
![Page 16: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/16.jpg)
INTRAOPERATIVE CONTAMINATION
Surgeon Factors
• Culture surgeon gloves & graft material
– 33% surgeons’ gloves imprints positive for S. epidermidis
– 75% grafts positive for S. epidermidis
• Glove change made no difference
• 25% of strains resistant to antibiotic !
•
![Page 17: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/17.jpg)
Classification and Presentation
![Page 18: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/18.jpg)
Aortic Graft Infections Bandyk classification
• Early (< 4 months) – gram + and gram – organisms
– entire graft infected
– More obvious (cellulitis/sepsis)
• Late (> 4 months) – usually > 1 year after implant
– S. epidermitis
– may not involve entire graft
– More subtle (drainage/PSA)
![Page 19: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/19.jpg)
Presentation
![Page 20: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/20.jpg)
![Page 21: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/21.jpg)
![Page 22: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/22.jpg)
![Page 23: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/23.jpg)
![Page 24: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/24.jpg)
Diagnosis of Graft Infection
![Page 25: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/25.jpg)
CT Scan
• Good for obvious signs:
– Perigraft fluid/air
– Pseudoaneurysm
– Aortic wrap disruption
• For low-grade infections:
– 100% specificity
– 55% sensitivity
![Page 26: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/26.jpg)
MRI
• Better to detect small
fluid collections
• Can differentiate
inflammation vs.
hematoma
• T2 weighted images
![Page 27: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/27.jpg)
Diagnosis of AEF
• EGD?
- Not specific
- Not sensitive
• CTA
- Air around graft
![Page 28: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/28.jpg)
![Page 29: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/29.jpg)
Treatment Options
![Page 30: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/30.jpg)
Conservative Management
• Very sick patients / Critical location
• Low-virulence organisms
• Drain infected perigraft space + irrigation
• Life-long antibiotics
![Page 31: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/31.jpg)
Conservative Management
(cont’d)
• 30 – 40 % death at one
year due to sepsis
• Contraindications
– AEF
– Virulent organisms
– Anastomotic
aneurysms
![Page 32: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/32.jpg)
Partial Excision
• Localized infection
− Femoral portion
• Low virulence
organisms
• In situ vs. extra-
anatomic
![Page 33: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/33.jpg)
Total Graft Excision
![Page 34: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/34.jpg)
Revascularization Options
Temporary/unusual
• Prosthetic graft
• Cryopreserved allograft
• Endovascular grafts
Permanent cure
• Extra-anatomic bypass
• Autogenous vein
![Page 35: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/35.jpg)
Total Excision Extra-Anatomic Bypass
![Page 36: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/36.jpg)
![Page 37: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/37.jpg)
Excision/Ectopic Bypass problems
• Thrombosis of ectopic bypass -- Primary patency 43% at 3 years
-- Limb loss 33% (UCLA series, arch Surg ’91)
• Reinfection of ectopic bypass 15%
• Aortic stump blowout
![Page 38: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/38.jpg)
Replace with Prosthetic Graft
Rifampin-soaked Dacron Silver-impregnated Dacron
![Page 39: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/39.jpg)
Prosthetic Graft limited use!
• May be appropriate for limited infections
− Aortoenteric fistula
− 15-20% reinfection rate
• Rifampin, Silver impregnated grafts
– low virulence organisms (10% reinfection)
– virulent organisms (40% reinfection)
• Bridge procedure??
![Page 40: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/40.jpg)
Cropreserved Aortic Graft
• Requires 1-2 days to obtain
– 30 minute prep time
• ABO compatibility?
• Excellent early results
– Resistant to most infections
– Easy handling
![Page 41: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/41.jpg)
Cryopreserved Aortic Graft
problems
• Side branch rupture
– 10-20% acute bleeding
• Worse outcome in AEF
• 10-20% late graft failure
– AEF
– Pseudoaneurysms
![Page 42: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/42.jpg)
Replace with Autogenous Vein
Neo-Aortoiliac System (NAIS)
Reconstruction
(Clagett Procedure)
![Page 43: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/43.jpg)
![Page 44: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/44.jpg)
![Page 45: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/45.jpg)
![Page 46: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/46.jpg)
![Page 47: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/47.jpg)
![Page 48: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/48.jpg)
![Page 49: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/49.jpg)
![Page 50: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/50.jpg)
Primary Patency
Assist Primary/Secondary Patency
81.7%
91%
0
10
20
30
40
50
60
70
80
90
100
0 12 24 36 48 60 72 84 96
Pat
en
cy (%
)
Months
![Page 51: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/51.jpg)
Limb Salvage
92.5%89.1%
0
10
20
30
40
50
60
70
80
90
100
0 12 24 36 48 60 72 84
Lim
b S
alva
ge %
Months
![Page 52: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/52.jpg)
UTSW experience
1990-2011
• 250 operations
• 2325 hours
• 1875 Units transfused
• Results:
– 90% patency
– 90% limb salvage
– 10% mortality
![Page 53: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/53.jpg)
Endovascular Option
…theoretically unappealing!
![Page 54: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/54.jpg)
Infected EVAR
a new problem
![Page 55: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/55.jpg)
![Page 56: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/56.jpg)
• Mycotic AAA: 25% recurrent infection
• AEF: 44% recurrence at 13 months
• ABF: 10% recurrence at 12 months
![Page 57: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/57.jpg)
Endovascular Utility?
…temporary control of bleeding
![Page 58: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/58.jpg)
Salmonella Aortitis
• Septic
• Acute MI
• Ruptured aneurysm
• Hypotensive
![Page 59: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/59.jpg)
Temporary EVAR Coverage
• Rapid access to aorta
• Potential for balloon
occlusion
• EVAR deployed
![Page 60: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/60.jpg)
Temporary EVAR Coverage
• Immediate BP stable
• Allowed 6 weeks
– IV antibiotics
– MI recovery
– Cardiac rehab
• Brought back for
definitive Tx
![Page 61: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/61.jpg)
Outcome
• Complete recovery
• Returned to work,
normal life
• Graft patent, no re-
infection
![Page 62: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/62.jpg)
![Page 63: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/63.jpg)
Summary
• Aortic graft infections
− Rare
− Wide range of presentation
• Multiple options for treatment
− Individualize
− Few = permanent cure
• Endovascular option = temporary
− May be life saving!
![Page 64: The Utility of the Femoral Vein As a Vascular Conduit](https://reader033.vdocuments.us/reader033/viewer/2022053112/6291ef31c01efd0e4a3a26ee/html5/thumbnails/64.jpg)