A unique inlet [the ascending aorta] for extra-anatomic bypass of infected arterial prostheses

Abstract

Infection is the most dreaded complication associated with implantation of a prosthetic arterial graft. The reported incidence of primary graft infection varies from 1.3% to 6.0%, with a mortality rate from this complication as high as 75%. Although remote bypass followed by complete removal of the infected prosthesis has proven to be a satisfactory method of treatment, in certain instances remote bypass alone is not feasible and other modes of surgical treatment must be employed. Such conservative methods of management of infected aorto-iliac-femoral prosthesis sometimes irradicate infection. The only certain cure, however, is obtained by totally removing the graft. And the success of extra-anatomic axillofemoral techniques has led to its extended use. The addition of a cross-limb on an axillo-unilateral femoral graft to form an axillobilateral femoral graft was described by Sauvage and Wood, reasoning that the higher flow rate in the axillary limb of the axillobilateral femoral graft would result in an improved patency rate compared with that of axillounilateral femoral grafts. Additionally, both medial (obturator foramen) and lateral extra-anatomic remote bypass of infected femoral prosthesis have been used, successfully. The current case illustrates the complexity of management, once sepsis occurs. It further focuses on groin, retroperitoneal and bilateral axillo-femoral tract infection with prolonged (apparently innocuous) graft exposure and finally points out the utility of the ascending aorta as an alternative extra-anatomic inlet to perfuse the lower extremities.