Chapter 30: Arterial Disease

Chapter 30: Arterial Disease

A 62-year-old man who underwent the procedure shown in Figure 30-1 1 year ago presents with fever, abdominal pain, an ileus, and an elevated white blood cell (WBC) count. A WBC scan confirms graft infection. Which of the following is true?

FIGURE 30-1. Endovascular aneurysm repair.

(A) The most common organism is Bacteroides fragilis.

(B) The risk of graft infection in this location is between 5 and 10%.

(C) Treatment consists of 6 weeks of broad-spectrum antibiotic coverage only.

(D) Implantation of a graft in an infected field is associated with 100% mortality.

(E) If surgery is performed, an axillobifemoral bypass should be constructed prior to graft excision if possible.

(E) Graft infections are a difficult problem for vascular surgeons; fortunately, the incidence of aortoiliac graft infection is fairly low at about 1.5%. Early graft infections (<4 months after bypass) are most often caused by Staphylococcus aureus, although later graft infections most often result from Staphylococcus epidermidis. Antibiotics alone are insufficient treatment for an aortic graft infection, but may occasionally be used in patients who are poor surgical candidates.

Aortic graft infections are best treated with graft excision and extra-anatomic bypass, such as an axillobifemoral bypass. A staged procedure is completed with extra-anatomic bypass first, followed by explantation of the infected graft several days later. Patients who present in extremis may require immediate explantation of the graft followed by a limb salvage procedure.

Szilagyi’s classification

• Grade I: cellulitis involving the wound

• Grade II: infection involving subcutaneous tissue

• Grade III: infection involving the vascular prosthesis

Bunt’s classification modified:

• Peripheral graft infection:

  • P0 graft infection: infection of a cavitary graft

  • P1 graft infection: infection of a graft whose entire anatomic course is noncavitary

  • P2 graft infection: infection of the extracavitary portion of a graft whose origin is cavitary

  • P3 graft infection: infection involving a prosthetic patch angioplasty

• Graft-enteric erosion

• Graft-enteric fistula

• Aortic stump sepsis after excision of an infected aortic graft

BIBLIOGRAPHY

Cronenwett JL, Johnston KW. Rutherford’s Vascular Surgery, 8th ed. Philadelphia, PA: Saunders; 2014.

Desai SS, Shortell CK (ed.). Clinical Review of Vascular Surgery. New York, NY: Catalyst Publishers; 2010.

Figure 30-2 shows the aortogram of a 57-year-old male patient. Which of the following findings is this patient most likely to have on evaluation?

FIGURE 30-2. Aortogram.

(A) Buttock and thigh claudication

(B) Small bowel necrosis