”MANAGEMENT OF INFECTED VASCULAR GRAFT”

JONATHAN GHOSHConsultant Vascular & Endovascular Surgeon

2 May 2012

INCIDENCE

CAROTID <1%INFRAINGUINAL 5-8%AXILLOFEMORAL 8%

AORTA 2-3% ( rupture or groin involvement)

24% subcutaneous (Szilagyi II) infections graft infection 22% death / amputation

Source: Joint Vascular Research Group

MANAGEMENT

PREVENTION

4 PRINCIPLESCONTROL HAEMORRAGE (RISK)ERADICATE INFECTIONOPTIMISE DISTAL PERFUSIONMINIMISE MORBIDITY / MORTALITY

AORTIC GRAFT INFECTION

PRESENTATION:

AORTIC GRAFT INFECTION

ACUTE

Aortoenteric fistulaAbscess / SinusSepticaemiaGraft thrombosisSeptic emboli

CHRONIC

DiscomfortMalaiseWeight lossAnorexiaAnaemia

PRESENTATION:

INFECTED STENT

STRUT OF STENT PENETRATING THROUGH DUODENUM

Gas around metal strut

MICROBIOLOGY

AORTIC GRAFT INFECTION

Staphylococcus epidermis Staphylococcus aureusEscherichia coli

EnterococcusNon-haemolytic streptococcusPseudomonasProteusMRSA

Culture negative 20%Poly / Atypical 10%+

AORTIC GRAFT INFECTIONMICROBIOLOGY

60%

AORTIC GRAFT INFECTION

INVESTIGATION

GAS BUBBLES

PERIGRAFT COLLECTION

PSEUDO ANEURYSM

OPTIONS:

AORTIC GRAFT INFECTION

OPTIONS:

AORTIC GRAFT INFECTION

NON INTERVENTIONAL – NON-CURATIVE

ENDOVASCULAR - TEMPORISING

SURGERY – DEFINITIVE BUT RISKTOTAL V PARTIAL GRAFT EXCISIONGRAFT REPLACEMENT V EXTRA-ANATOMICAL BYPASSDEEP VEIN V CRYOGRAFT V PROSPHETIC MORTALITY: 10-20(+)% 30 DAYS; 37(+)% 1 YEAR

DUODENAL EROSION

PROSTHETIC INFRA-INGUINAL

PRESENTATION

PROSTHETIC INFRA-INGUINAL

PRESENTATION

ABSCESSWOUND DISCHARGEEARLY AMPUTATIONRE-OPERATIONLIMB DETERIORATION

MEDIAN TIME FROM BYPASS TO INFECTION: 3 MONTHS

DUPLEX

PROSTHETIC INFRA-INGUINAL

OPTIONS

PROSTHETIC INFRA-INGUINAL

OPTIONS

GRAFT PRESERVATIONIRRIGATION AND VACUUM ASSITED CLOSUREMUSCLE FLAP

GRAFT EXPLANT +/- REPLACEMENT (VEIN / CRYOGRAFT)

…ALL WITH LONG TERM ANTIBIOTICS

GRAFT PRESERVATION

VACUUM ASSISTED CLOSURE

SUCCESSFUL 80%

UP TO 20% BLEED IF ANASTOMOSIS EXPOSED

LOW RECURRENCE REPORTED

1 WEEK

3 WEEKS4 WEEKS

GRAFT PRESERVATION

OVERVIEW

PREVENTION BETTER THAN CURE

DEFINITIVE TREATMENT IS DEBRIDEMENT – NOT ALWAYS ACHIEVABLE

GRAFT PRESERVATION IN PERIPHERY – WITH CAUTION