ALTERNATIVE APPROACH FOR MANAGEMENT OF INFECTED AORTIC GRAFTS

Purpose: Prosthetic infection after aortic reconstructive surgery hist orically has been treated with extraanatomical bypass, graft excision, and aortic stump closure, but at the cost of substantial mortality an d amputation rates. Alternatives to this strategy include in situ pros thetic replacement in the infected area, as well as autogenous reconst ructions. Inherent to all of these procedures, however, is either the creation of an aortic stump, which carries a significant risk of subse quent blowout, or the placement of a bypass conduit in the infected he ld, thereby maintaining the potential for subsequent infectious compli cations. To avoid such problems, we have used retroperitoneal in-line aortic bypass with polytetrafluoroethylene through clean tissue planes . Methods: Since 1987 we have treated 16 graft infections in this mann er. The surgical approach consisted of obtaining retroperitoneal proxi mal aortic control outside of the infected held (above or below the re nd arteries), followed by infrarenal division and oversewing of the di stal aorta. A polytetrafluoroethylene bifurcated graft was then sewn t o the proximal aorta and tunnelled through the psoas sheath laterally to the profunda femoris artery on the ipsilateral side and via the spa ce of Retzius to the contralateral appropriate femoral vessel, so as t o avoid any contact with the infected areas. After the closure of the wounds, a plastic barrier was placed over all incisions and the patien t was placed supine. The old infected graft was removed transperitonea lly. Extensive cultures were taken at various sites to demonstrate no cross-contamination.Results: All patients were followed-up clinically and with tagged white cell scans at 6-month intervals. There were no i mmediate postoperative deaths and no amputations. One patient had a my ocardial infarction and died at 5 months, and a second patient died at 2 months. Of the remaining 14 patients, none had recurrent sepsis and all have had negative Indium-labeled white cell scans in follow-up. E leven (78%) are still alive, with a mean follow-up of 32 months (range , 20 to 106 months). Conclusions: In-line aortic bypass for treatment of aortic graft infections yields excellent results and has become our treatment of choice in dealing with this difficult problem.