1. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
6 VASCULAR SYSTEM 13 Surgical Treatment of the Infected Aortic Graft — 1
13 SURGICAL TREATMENT OF THE
INFECTED AORTIC GRAFT
Victor J. D’Addio, M.D., F.A.C.S., and G. Patrick Clagett, M.D., F.A.C.S.
In dealing with an infected aortic graft, the primary goal of treat- mortality was associated with this method of treatment.2 In addi-
ment is to save life and limb. This goal is best accomplished by tion, many survivors experience significant problems, including
eradicating all infected graft material and maintaining adequate early or late allograft rupture and late aortic graft dilation.3
circulation with appropriate vascular reconstruction. Secondary Reinfection of allografts may also occur and usually proves fatal
goals are to minimize morbidity, to restore normal function, and to when it does. Complications may be reduced by using cryopre-
maintain long-term function without the need for repeated inter- served allografts instead of fresh ones, but at present, the data are
vention or amputation. insufficient to determine whether one type of allograft is clearly
Before definitive reconstruction, all infected graft material must superior to the other overall. Currently, aortic allografts are avail-
be debrided, along with any grossly infected vascular tissue and able in the United States only on a limited basis; accordingly, this
surrounding soft tissue. Once debridement is complete, there are technique is not a useful option in emergency situations.
several options for reconstruction, including (1) extra-anatomic
ANTIBIOTIC-TREATED PROSTHETIC GRAFT
bypass, (2) use of an arterial allograft, (3) placement of vascular
prostheses treated with or soaked in antibiotic solutions, and (4) Use of antibiotic-treated prosthetic graft material for recon-
in situ replacement with a femoral-popliteal vein (FPV) graft.The struction has the advantage of permitting an expeditious recon-
choice among these options is made on the basis of the specific struction that leaves no aortic stump.2,4-8 However, the reinfection
clinical situation present. The primary focus of the technical rate is high and unpredictable, and patients must undergo lifelong
description in this chapter, however, will be on the fourth option antibiotic therapy. Typically, the new prosthetic graft is soaked in
[see Operative Technique, below]. rifampin, 60 mg/ml, for 15 minutes before implantation.6,7
IN SITU AUTOGENOUS RECONSTRUCTION
Choice of Procedure Dissatisfaction with the long-term patency of extra-anatomic
bypass led to the development of in situ autogenous venous recon-
EXTRA-ANATOMIC BYPASS
struction.9-11 Early reconstructive attempts that made use of
Extra-anatomic bypass, usually performed as an axillobifemoral greater saphenous vein grafts proved unsuccessful because the
bypass [see Figure 1 and 6:12 Aortoiliac Reconstruction], is a good small caliber of the venous conduit resulted in low patency rates.
option for treatment of an infected aortic graft when groin infec- Subsequent attempts that made use of larger-caliber FPV grafts,
tion is absent and lower-extremity runoff is good. The primary however, proved highly successful.
advantages of extra-anatomic bypass are that it minimizes lower- FPV grafts have excellent long-term patency and are resistant
extremity ischemic time and that it is less of a physiologic insult to reinfection. In addition, they are ideal conduits for patients with
than an aorta-based bypass procedure (mainly because it is typi- extensive multilevel occlusive disease, in whom venous grafts the-
cally done in a staged fashion). The primary disadvantages are oretically would have better patency than prosthetic grafts. (An
that long-term patency is poor and that there is a significant risk analogy would be the superior durability of venous grafts for
of reinfection. In addition, if groin infection is present, the bypass femoropopliteal bypass in comparison with prosthetic grafts.) The
is compromised even further by the need to use vessels such as the 5-year patency rates for aortoiliac/aortofemoral reconstructions
profunda femoris artery or the popliteal artery for distal targets. using FPV grafts range from 85% to 100%.11,12 Long-term ampu-
Bilateral axillofemoral bypasses are often required in this situation. tation rates are correspondingly low.
Because of these factors, the durability of an extra-anatomic bypass The primary disadvantage of reconstruction with FPV grafts is
may be limited despite aggressive antithrombotic treatment. that the procedure is time consuming and technically demanding.
Extra-anatomic bypasses are plagued by sudden thrombotic In our experience, the mean operating time is about 8 hours.The
occlusion, and amputation rates are high. In one large series, one lower-extremity ischemic time is longer than that in patients
third of patients required a major amputation during long-term undergoing extra-anatomic bypass, but it can be minimized by
follow-up.1 Reinfection also is a major concern when prosthetic sequencing the operation so as to shorten cross-clamp time and
grafts are employed in patients with ongoing infection: it occurs in by using a two-team approach. An additional disadvantage of
10% to 20% of such patients and often proves lethal. A final major using FPV grafts is the associated short-term venous morbidity.
concern in patients who undergo excision of an infected aortic Approximately 20% of patients who undergo FPV harvesting will
graft and extra-anatomic bypass is the possibility of blowout of the require fasciotomy, typically performed at the time of the harvest.
aortic stump.This is an infrequent occurrence (incidence < 10%) The fasciotomy rate is highest in patients who undergo concur-
but one that is typically fatal. rent greater saphenous vein harvesting and in those who have
severe lower-extremity ischemia (ankle-brachial index [ABI]
AORTIC ALLOGRAFT
< 0.4).13 Long-term venous morbidity appears to be low, with no
In situ aortic allografting has been employed to treat aortic graft known cases of venous ulceration or venous claudication.14 Mild
infections, with somewhat mixed results. In one report, a 20% to moderate chronic edema develops in approximately 30% of

2. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
6 VASCULAR SYSTEM 13 Surgical Treatment of the Infected Aortic Graft — 2
Figure 1 Standard treatment of aortic graft
infection involves axillobifemoral bypass, removal
of the infected prosthesis, and oversewing of the
aortic stump. This procedure can be performed in
either one or two stages. It is most useful in
patients who do not have infection extending into
the femoral area.
patients. Aneurysmal degeneration of the vein grafts is a theoreti- nance angiography can also be a helpful adjunct, particularly in
cal risk, but in practice, it is rare. patients with renal insufficiency.
When autogenous reconstruction with deep vein grafts is being
considered, preoperative assessment of the adequacy of the vein seg-
Preoperative Evaluation ments must also be performed.This is accomplished by means of ve-
The preoperative workup should assess the extent of infection, nous duplex ultrasonography. Duplex examination of the lower-ex-
look for concomitant occlusive disease (indicating a possible need tremity venous system establishes the diameter and the available
for infrainguinal, visceral, or renal reconstruction), and determine length of the deep veins. In addition, the duplex scan can evaluate
whether there are other associated infectious complications that acute or chronic thrombosis of the deep veins, any recanalization
must be treated surgically (e.g., a psoas abscess, an entrapped changes, the congenital absence or duplication of venous segments,
ureter with hydronephrosis, or duodenal erosion necessitating and unusually small deep veins.When the FPV is small (< 5 mm),
duodenal repair). In patients who have previously undergone absent, or incomplete, a dominant profunda femoris vein is usually
prosthetic aortofemoral bypass, infection may be limited to one present.This vein courses posteriorly through the thigh to connect
limb of the graft, and it may be treatable by replacing only that with the popliteal vein and can also be used as a venous autograft.
limb. In patients who have previously undergone prosthetic Duplex vein mapping of the greater saphenous system is also rou-
infrainguinal bypass, the prosthetic graft may have to be removed tinely performed and may provide useful information in the event
and replaced with an autogenous graft. that concomitant infrainguinal reconstruction is planned or may
Traditionally, the mainstay of the preoperative workup was arte- have to be performed unexpectedly.
riography complemented by computed tomography, but current-
ly, the workup is increasingly being performed with CT angiogra-
phy alone. CT angiography is often capable of evaluating the Operative Planning
extent of infection, visualizing the sites of previous prosthetic anas- Removal of an infected aortic graft and autogenous reconstruc-
tomoses, and delineating the arterial anatomy. Magnetic reso- tion require prolonged exposure of large portions of the body sur-

3. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
6 VASCULAR SYSTEM 13 Surgical Treatment of the Infected Aortic Graft — 3
Care must also be taken to preserve major branches of the
superficial femoral artery when this vessel is occluded or severely
diseased. Interruption of these branches, which may supply collat-
eral circulation to distal beds, may result in unexpected critical
ischemia of the lower extremity after completion of the proximal
reconstruction, and further infrainguinal arterial reconstruction
may be necessary.
STEP 2: DISSECTION OF FPV
The FPV has many large and small side branches. Careful, metic-
ulous and unhurried ligation of these branches is critical. Most are
doubly ligated, with suture ligation reserved for the larger ones.
Failure to ligate a branch adequately will result in exsanguinating
hemorrhage if a tie loosens and pops off when exposed to aortic
pressure. Although as a rule, the FPV is larger and sturdier than the
typical greater saphenous vein, it is thin-walled in some areas where
branches are present. If a branch is avulsed during dissection, suture
repair with 6-0 or 7-0 polypropylene is necessary. Branch ligation
during FPV harvesting differs from the typical branch ligation dur-
Figure 2 The FPV (thin black arrow), the superficial femoral ing saphenous vein harvesting.The branches of the FPV are ligated
artery (thick white arrow), and the saphenous nerve (thin white close to their bases because this is where the vein wall tends to be
arrow) lie deep to the sartorius (thick black arrow) in the sub-
thin; the larger caliber of the FPV makes this technique possible. In
sartorial canal. The sartorius is reflected medially to expose
these structures. The adductor magnus tendon is divided to
contrast, the branches of the greater saphenous vein, which is of
expose these structures as they traverse Hunter’s canal. smaller caliber, are ligated slightly away from the vessel wall to
ensure that the lumen of the vein is not encroached on.
The extent of the harvest depends on the length of venous con-
face. Significant drops in core body temperature, combined with duit required for reconstruction. Proximally, dissection extends to
blood loss and resuscitation, may lead to metabolic acidosis, coag- the level of the junction of the femoral and profunda femoris veins.
ulopathy, cardiac dysrhythmia, and immune compromise. These veins join to form the common femoral vein, which is also
Accordingly, core body temperature should be kept above 36° C exposed in the dissection.The profunda femoris vein is easily rec-
(96.8° F) by applying heated-air warming blankets to the upper ognizable as a large posteriorly penetrating vein in the proximal
body, using warmed fluid for resuscitation, and maintaining a thigh. Distally, dissection is carried through the adductor hiatus by
warm ambient temperature in the operating room. dividing the tendon of the adductor magnus; this measure allows
To minimize ischemic time with cross-clamping, the major easy access to the proximal portion of the popliteal vein. The
tasks involved in excision of an infected aortic graft and in situ popliteal segment of the vein has multiple large branches, which
autogenous reconstruction should be sequenced as follows: (1) must be carefully ligated.The dissection can easily be taken down
dissection of FPVs, which are left in situ until needed; (2) isola- to the level of the knee joint. The veins are left in situ until the
tion and control of the femoral vessels; (3) entry into the abdomen required length of conduit can be determined.
and control of the aorta; (4) removal of the infected prosthesis;
and (5) reconstruction with the deep vein grafts.15 STEP 3: DISSECTION AND CONTROL OF FEMORAL VESSELS
The femoral vessels can usually be dissected by extending the vein
Operative Technique harvest incision cephalad along the lateral border of the sartorius to
STEP 1: THIGH INCISION AND EXPOSURE OF FEMORAL VESSELS
The patient is placed in the supine position with the legs “frog-
legged” and supported under the thighs. An incision is made on
the thigh along the lateral border of the sartorius muscle.This lat-
eral incision not only facilitates vein harvesting but also allows the
surgeon to expose the femoral vessels while avoiding the infected
femoral incision medially in the groins.
The sartorius is reflected medially so as to preserve the medi-
al segmental blood supply.The subsartorial canal is entered, and
the femoral vessels are exposed. The femoral vein is usually
located posterior to and slightly medial or lateral to the artery at
this level. The deep venous system is then exposed from the dis-
tal common femoral vein downward, including the proximal
profunda femoris vein through Hunter’s canal to the mid-
popliteal level [see Figure 2]. The saphenous nerve is located in
this canal and is intimately associated with the femoral vessels. Figure 3 Use of a valvulotome typically results in incomplete
Care must be taken not to injure this nerve either directly or valve lysis. It is preferable to evert the entire venous graft and
through excessive traction; such injury will cause irritating post- excise the valves (which usually number 3 or 4) completely with
operative saphenous neuralgia. scissors.

4. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
6 VASCULAR SYSTEM 13 Surgical Treatment of the Infected Aortic Graft — 4
a b c
d e
Figure 4 Multiple anatomic reconstructions have been used to recreate the aorto-iliac-femoral anato-
my. (a) Shown is an aortounifemoral bypass with a femorofemoral crossover. (b) Instead of a femoro-
femoral bypass, the second limb may be brought off the midportion of the first limb in an end-to-side
manner. (c) If infection is limited to one limb of an aortofemoral bypass, an FPV graft may be used to
replace only the infected portion. (d) One segment of vein may be used to replace both segments of an
aortoiliac or aortofemoral graft. (e) In some instances, it may be easier to approach the paraceliac
aorta via a retroperitoneal approach for the proximal anastomosis.
STEP 5: REMOVAL AND PREPARATION OF VENOUS GRAFTS
the level of the anterior superior iliac spine. Through this incision,
control of the superficial femoral, profunda femoris, and common Before cross-clamping, the vein grafts are removed and pre-
femoral vessels is gained. In addition, the distal limbs of the existing pared. The length of the grafts is determined by measuring from
aortofemoral graft can be controlled. Occasionally, control is difficult the aortic anastomosis to the femoral anastomoses on both sides.
to obtain from a position lateral to the sartorius, in which case the The femoral vein is divided flush with the profunda femoris vein
medial aspect of the muscle may be dissected from the subcutaneous and oversewn with a 5-0 polypropylene suture. This creates a
tissue to afford improved exposure. Only rarely is a more medial inci- smooth transition point from the profunda femoris vein to the
sion required. As noted [see Step 1, above], the lateral approach al- common femoral vein and leaves no stump in which blood can
lows the surgeon to avoid entering the previous incision, where there stagnate and create thrombus. The grafts are then distended in a
may be a draining sinus or cellulitis. 4° C solution containing lactated Ringer solution (1 L), heparin
(5,000 U), albumin (25 g), and papaverine (60 mg). Any leaks are
STEP 4: ABDOMINAL INCISION AND DISSECTION OF AORTA repaired either with additional silk ties or with figure-eight fine
The abdomen is then entered either through a midline abdomi- polypropylene sutures. Any adventitial bands that distort the
nal incision or via a retroperitoneal approach; the latter is particu- lumen are lysed.
larly helpful in avoiding tedious abdominal adhesions. Dissection Next, the valves in the grafts must be lysed.This is a critical step
for control of the aorta above the aortic anastomosis is performed. because the grafts are placed in a nonreversed fashion to optimize
The anastomosis may be near the level of the renal arteries, in which size matching with the aorta for the proximal anastomosis.
case suprarenal or supraceliac aortic control may be required. Valvulotomes have been used for valve lysis in these large-caliber

5. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
6 VASCULAR SYSTEM 13 Surgical Treatment of the Infected Aortic Graft — 5
veins, but the results have been unsatisfactory: lysis is often incom- formed so as to cut down on the blood loss that typically occurs
plete, and the remnants of the valves may become sites of graft when the limbs are removed from their tunnels.
stenosis. Our current practice is to evert venous grafts completely Multiple configurations have been successfully employed to
and to excise all valves under direct vision [see Figure 3]. reconstruct the distal aortic and iliac-femoral vasculature [see
Figure 4].The proximal anastomosis is performed with a continu-
STEP 6: REMOVAL OF BODY OF PREVIOUS GRAFT AND
ous 4-0 polypropylene suture. The diameter of the FPV graft is
PROXIMAL ANASTOMOSIS OF NEW GRAFT TO AORTA
typically about 1.5 cm or a little greater, and the mismatch in
The patient is heparinized, and the aorta above the anastomo- diameter between the graft and the aorta is dealt with by taking
sis and both limbs of the graft are cross-clamped.The body of the slightly more advancement (i.e., placing sutures slightly farther
graft is then excised, with the limbs left in place. All prosthetic apart) on the aortic wall than on the graft wall [see Figure 5a]. If
material, including sutures, is removed. The previous aortic anas- the caliber discrepancy between the two structures is too large,
tomosis may have been done in either an end-to-end or an end- another technique must be employed, such as plication of the
to-side fashion. If it was an end-to-side anastomosis, the distal end aorta, joining of the venous grafts in a pantaloon configuration, or
of the aorta will have to be oversewn with a large suture (e.g., 0 or placement of a triangular patch at the proximal aspect of the graft
No. 1 polypropylene). Balloon occlusion of the distal lumen is a [see Figures 5b through 5d].
helpful adjunctive measure before ligation. Regardless of how the After the proximal anastomosis is complete, the venous graft is
previous aortic anastomosis was done, the new anastomosis is typ- distended under aortic pressure, and the side branches are care-
ically constructed in an end-to-end fashion.The distal limbs of the fully examined to confirm that all ligatures are securely placed.
existing graft are left in place while the aortic anastomosis is per- Any questionable areas are repaired. Anastomotic leakage is also
repaired with the aorta clamped to ensure that the venous graft is
not torn during repair.
a b STEP 7: REMOVAL OF LIMBS OF PREVIOUS GRAFT AND DISTAL
ANASTOMOSES OF NEW GRAFTS TO FEMORAL ARTERIES
The femoral limbs of the prosthetic aortobifemoral grafts are
then removed by pulling them through the groin incisions. When
the FPV grafts are tunneled to the groins, care must be taken to
ensure that ligated side branches are not torn or dislodged.
Because it may be difficult to create new tunnels through the
scarred retroperitoneum, the vein grafts may be tunneled through
the existing tunnels. In many cases, the existing tunnels are small-
er in caliber than the new vein grafts, and careful digital dilation
of the tunnels is required.
The femoral anastomoses are fashioned in a standard manner.
Once again, all prosthetic material and all surrounding infected
tissue must be debrided from the groins. On occasion, profun-
c d daplasty or reimplantation of the profunda femoris may be re-
quired. If possible, the femoral anastomoses should be done in an
end-to-side manner to preserve retrograde pelvic perfusion.
Perfusion of the extremities must be assessed before the leg
wounds are closed. If Doppler arterial signals are absent at the
level of the ankle, a femoropopliteal or distal bypass may be nec-
essary [see 6:17 Infrainguinal Arterial Procedures]. Because the
popliteal artery is exposed during FPV harvesting, adjunctive
femoropopliteal bypass is easily accomplished in this setting.
STEP 8: CLOSURE
After reversal of heparinization, the thigh wounds are copious-
ly irrigated and closed over closed suction drains. Placement of
drains prevents postoperative seromas and subsequent wound
complications. Even though these wounds are contaminated as a
consequence of the proximity of the infected graft in the groin
wound, infection is rare. Often, there are draining sinuses medial
to the vein harvest incisions, which are debrided and left open.
Figure 5 (a) An end-to-end proximal anastomosis is usually
possible if the diameter of the FPV graft is large enough and the
aorta is of normal size. (b) If the end of the aorta is significantly Postoperative Care
larger in diameter than the venous graft, plication of the aorta
can be performed. (c) A pantaloon technique may also be used to Parenteral antibiotics are continued for 5 to 7 days, and antibi-
deal with a size mismatch between the aorta and the FPV graft. otic coverage is modified on the basis of intraoperative cultures of
This technique effectively doubles the circumference of the vein. the graft material and wound swabs. Intermittent pneumatic
(d) The proximal anastomosis can also be facilitated by incorpo- compression and low-dose subcutaneous heparin (5,000 U every
rating a wedge-shaped portion of vein into the proximal end of 8 to 12 hours) are employed for prevention of deep vein thrombo-
the graft. sis.Thrombosis of the residual popliteal vein is common, and ag-

6. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
6 VASCULAR SYSTEM 13 Surgical Treatment of the Infected Aortic Graft — 6
gressive prophylaxis may prevent extension of the thrombus into ical examination of the legs.We specifically assess progressive com-
the calf veins. With the FPV absent, the risk of pulmonary em- partment swelling and firmness on serial examination after reper-
bolism is low. fusion of the lower extremities.We also consider risk factors in mak-
ing this decision. Two specific risk factors for fasciotomy are (1) a
low preoperative ABI (< 0.4) and (2) concurrent greater saphenous
Complications vein harvesting.13 Other factors may also help determine the need
The incidence of chronic venous morbidity after FPV harvesting for fasciotomy, including the indication for operation, the length of
is low, but the fasciotomy rate is approximately 20%. In our prac- vein harvested, the duration of arterial cross-clamping, and the
tice, the decision to perform a fasciotomy is based primarily on clin- amount of fluid administered intraoperatively.
References
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6. Hayes PD, Nasim A, London NJM, et al: In situ re- aortoiliac/femoral reconstruction from superficial Acknowledgment
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