”management of infected vascular graft”
DESCRIPTION
”MANAGEMENT OF INFECTED VASCULAR GRAFT”. JONATHAN GHOSH Consultant Vascular & Endovascular Surgeon. 2 May 2012. INCIDENCE. CAROTIDTRANSCRIPT
”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