- •Vascular Surgery
- •SECTION AND BOARD OF VASCULAR SURGERY
- •Foreword to the First Edition
- •Preface to the First Edition
- •Preface to the Second Edition
- •Preface to the Third Edition
- •Contents
- •Contributors
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •1.1 Commentary
- •1.2 Beta-Adrenergic Antagonists
- •1.3 3-Hydroxy-3-Methylglutaryl Coenzyme A Reductase Inhibitors (Statins)
- •1.4 Percutaneous Revascularization
- •1.5 Coronary Artery Bypass Grafting
- •References
- •2: Abdominal Aortic Aneurysm
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •2.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •Question 11
- •Question 12
- •Question 13
- •Question 14
- •3.1 Commentary
- •3.2 Case Analysis Quiz
- •References
- •4: Ruptured Abdominal Aortic Aneurysm
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •4.1 Commentary
- •References
- •5: Thoracoabdominal Aortic Aneurysm
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •5.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •Question 11
- •Question 12
- •Question 13
- •6.1 Commentary
- •References
- •7: Aortic Dissection
- •7.1 Dissection: Stanford A
- •Question 1
- •Question 2
- •Question 3
- •7.2 Dissection: Stanford B
- •Question 4
- •Question 5
- •7.3 Commentary
- •References
- •8: Popliteal Artery Aneurysms
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •8.1 Popliteal Artery Aneurysm
- •References
- •9: Renal Artery Aneurysm
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •9.1 Commentary
- •References
- •10: Anastomotic Aneurysms
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •10.1 Commentary
- •10.2 Indications for Intervention
- •10.3 Treatment for Anastomotic Aneurysms
- •10.4 Infection in Anastomotic Aneurysms
- •10.5 Outcome
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •11.1 Commentary
- •References
- •12: Acute Thrombosis
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •12.1 Commentary
- •References
- •13: Arterial Embolism
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •13.1 Commentary
- •References
- •14: Blast Injury to the Lower Limb
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •14.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •15.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Smoking
- •Antiplatelet Agents
- •Blood Pressure (BP)
- •Glucose Status
- •Lipids
- •Emerging Risk Factors
- •Question 4
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •Question 11
- •17.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •18.1 Commentary
- •18.2 Clinical Assessment
- •18.3 Imaging Techniques
- •18.4 Revascularization Options
- •18.5 Aortobifemoral Bypass
- •18.6 Iliac Angioplasty and Stenting
- •18.7 Iliac Stenting Combined with Profunda Femoris Artery Revascularization
- •18.8 Rationale for Angioplasty of “Donor” Iliac Artery Prior to Femorofemoral Crossover Bypass
- •18.10 Supervision and Follow-up of the Patient
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •Question 11
- •Question 12
- •19.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •20.1 Commentary
- •References
- •21: Bypass to the Popliteal Artery
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •21.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •22.1 Commentary
- •References
- •23: Popliteal Artery Entrapment
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •23.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •24.1 Commentary
- •References
- •25: The Obturator Foramen Bypass
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •25.1 Commentary
- •25.2 Preoperative Measures
- •25.3 The Concept of the Obturator Foramen Bypass
- •25.4 Obturator Foramen Bypass Technique
- •References
- •26: Diabetic Foot
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •Question 11
- •26.1 Commentary
- •References
- •27: Chronic Visceral Ischemia
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •27.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •28.1 Commentary
- •References
- •29: Renovascular Hypertension
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •29.1 Commentary
- •29.4 Intra-arterial Angiography
- •29.5 Duplex Ultrasonography (DU)
- •29.6 Treatment
- •29.6.1 Medical Treatment
- •29.6.2 Revascularization
- •29.7 Prognosis
- •References
- •30: Midaortic Syndrome
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •30.1 Commentary
- •References
- •31: Management of Portal Hypertension
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •31.1 Commentary
- •31.2 General Considerations
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •32.1 Commentary
- •References
- •33: The Carotid Body Tumor
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •33.1 Commentary
- •33.2 Clinical Presentation
- •33.3 Treatment
- •33.4 Summary
- •References
- •Question 1
- •Question 2
- •Question 3
- •34.1 Commentary
- •34.2 Vertebrobasilar Ischemia: Low-Flow Mechanism
- •Question 1
- •Question 2
- •34.3 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •35.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •36.1 Commentary
- •References
- •37: Acute Axillary/Subclavian Vein Thrombosis
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •37.1 Commentary
- •References
- •38: Raynaud’s Phenomenon
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •38.1 Commentary
- •References
- •39: Aortofemoral Graft Infection
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •39.1 Commentary
- •References
- •40: Aortoenteric Fistulas
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •40.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •41.1 Commentary
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Questions 7 and 8
- •Question 9
- •Question 10
- •Comment
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •42.1 Commentary
- •References
- •43: Amputations in an Ischemic Limb
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •43.1 Commentary
- •References
- •44: Congenital Vascular Malformation
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •44.1 Clinical Evaluation
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •Question 11
- •44.2 Commentary
- •References
- •45: Klippel-Trenaunay Syndrome
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •45.1 Commentary
- •Clinical Presentation
- •Evaluation
- •Treatment
- •References
- •46: Deep Venous Thrombosis
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •46.1 Commentary
- •References
- •47: Endoluminal Ablation of Varicose Veins
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •47.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •48.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •50.1 Commentary
- •References
- •51: Iliofemoral Venous Thrombosis
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •50.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •Question 11
- •52.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •Question 6
- •Question 7
- •Question 8
- •Question 9
- •Question 10
- •53.1 Commentary
- •References
- •Question 1
- •Question 2
- •Question 3
- •Question 4
- •Question 5
- •54.1 Commentary
- •References
- •Index
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Aortofemoral Graft Infection |
39 |
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Christopher P. Gibbons |
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A 66-year-old man, an ex-smoker with hypertension and hypercholesterolaemia, had undergone a Dacron bifurcated aortic graft and bilateral ureteric stents for an inflammatory aortic aneurysm with ureteric obstruction at another hospital 4 years previously. The left limb of the graft had been anastomosed to the common femoral artery and the right limb to the common iliac bifurcation. Postoperatively he had suffered a mild groin wound infection, which had healed with antibiotics. At follow-up he complained of left calf and thigh claudication. On examination, he appeared generally well with a midline abdominal scar and a left vertical groin scar. He had good right femoral pulse but an absent left femoral pulse.
Question 1
What should be the first investigation?
A. Intra-arterial digital subtraction angiography (DSA). B. Duplex ultrasound scan of the aortic graft.
C. 99Technetium-labelled leucocyte scan. D. CT angiography of the graft.
E. Erythrocyte sedimentation rate (ESR).
A duplex scan showed an occluded left limb of the aortic graft with patent common femoral arteries. There was no evidence of any stenosis of the left common femoral artery but a perigraft fluid collection was noted around the intra-abdominal portion of the graft.
C.P. Gibbons
Department of Vascular Surgery, Morriston Hospital, Swansea, UK
G. Geroulakos and B. Sumpio (eds.), Vascular Surgery, |
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DOI: 10.1007/978-1-84996-356-5_39, © Springer-Verlag London Limited 2011 |
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398 |
C.P. Gibbons |
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Question 2
What further investigations should be performed?
A.CT scan of the graft.
B.Digital subtraction angiography.
C.99Technetium-labelled leucocyte scan.
D.Erythrocyte sedimentation rate.
E.Aspiration of the collection.
A CT scan confirmed the presence of fluid and gas around the intra-abdominal portion of the graft and the occlusion of the left limb, indicating graft infection (Fig. 39.1). Digital subtraction angiography (Fig. 39.2) confirmed the occluded left limb of the aortic graft and showed a stenosis at the origin of the right graft limb, presumably as a result of external compression. Aspiration of the perigraft collection would have allowed preoperative bacterial culture but was considered to be too difficult to perform safely.
Fig. 39.1 CT scan of aortic graft showing fluid and a gas bubble around the graft
Fig. 39.2 Intra-arterial digital subtraction angiography (DSA) of the aortoiliac region
39 Aortofemoral Graft Infection |
399 |
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Question 3
Having confirmed the presence of infection what is the best option for management?
A. Prolonged antibiotic therapy.
B. Drainage of the perigraft pus under anaesthesia. C. Insertion of gentamicin beads.
D. Excision of the graft.
E. Excision of the graft with in situ replacement with an antibiotic bonded graft. F. Graft excision and extra-anatomical prosthetic bypass.
G. Graft replacement with autologous vein. H. Graft replacement with an aortic allograft.
In situ replacement with autologous vein was chosen because of the reduced risk of persistent infection.
Question 4
Which autologous veins may be used for aortoiliac or aortofemoral graft replacement?
A. Long saphenous vein. B. Cephalic vein.
C. Femoropopliteal vein. D. Iliac vein.
Femoropopliteal vein was used as it is ideally suited to supra-inguinal graft replacement as it is relatively thick-walled, is of adequate diameter and has sufficient length.
Question 5
What further preoperative investigations should be performed?
A. Plain abdominal X-ray. B. Bone scan.
C. MRI scan of the abdomen.
D. Duplex scan of the femoral veins. E. Repeat abdominal ultrasound scan.
A duplex scan of the femoral veins confirmed that they were patent and of adequate calibre. The patient was operated on electively on the next available operating list.
Question 6
What other preoperative preparations should be undertaken?
A. Routine full blood count.
B. Urea and electrolyte estimation.
400 |
C.P. Gibbons |
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C. Chest X-ray and electrocardiogram (ECG). D. Compression stockings.
E. Subcutaneous heparin.
F. Combination antibiotic therapy.
Routine blood investigations, chest X-ray and ECG were all performed, and in view of the magnitude of the procedure, echocardiogram and lung function tests were also ordered. They were all satisfactory. Because the bacteriology of the infection was not known preoperatively in this patient, intravenous combination antibacterial therapy with teicoplanin, ciprofloxacin, co-amoxiclav and metronidazole was given immediately before surgery.
Question 7
How should the operation be performed?
A. Laparotomy, excision of the aortic graft, harvesting of the femoral veins and graft replacement.
B. Harvesting of femoral veins followed by laparotomy, excision of the infected graft and replacement with femoral vein.
C. Laparotomy and exposure of the infected graft, then femoral vein harvest followed by graft replacement.
The anaesthetised patient was catheterised, prepared and draped so that the abdomen and both legs were exposed. First, both superficial femoral veins were simultaneously dissected out by two operative teams and the branches divided between clips from the profunda femorisveintothekneejoint.Thefemoralveinswereleftinsituwhilsttheabdomenwasopened, exposing the graft and obtaining control of the proximal infrarenal aorta and the right commoniliacbifurcation.Thegraftwasencasedinfibroustissue,makingdissectiondifficultand hazardous.Theunderlyingprosthesisshowedpoortissueincorporationandtherewasalocalised abscess between the graft and the duodenum, which was evacuated and cultured. The left groin was exposed, obtaining control of the common femoral artery, its branches and the profunda femoris artery. After systemic heparinisation, the vessels were clamped and the infected graft excised and sent for culture. The graft bed was washed repeatedly with povidone iodine and hydrogen peroxide. One femoral vein was excised, reversed and inserted end-to-end from the infrarenal aorta to the right common iliac artery bifurcation using 4/0 polypropylene sutures. Size discrepancy at the aortic anastomosis was overcome by “fishmouthing”theendoftheveintopreventtheangulationassociatedwithspatulation(Fig.39.3). Theotherfemoralveinwasreversedandanastomosedendtosidetotheintra-abdominalpart of the vein graft and to the left common femoral artery (Fig. 39.4). Both veins were led through a fresh tunnel and surrounded by greater omentum to avoid contact with the bed of the infected graft. The arterial anastomoses were covered by gentamicin-impregnated collagenfoamandthewoundswereclosedwithsuctiondrainage.Antibioticprophylaxisandlow molecular weight heparin were continued postoperatively. Despite the copious pus around the graft, no organisms were grown in the laboratory. Combination antibiotic therapy was stopped after 7 days but co-amoxiclav was continued empirically for a further 5 weeks.