Outcomes of unilateral graft limb excision for infected aortobifemoral graft limb

Abstract

Objective: Aortobifemoral graft (ABFG) infections presenting with apparent single-limb involvement can be managed with unilateral graft limb excision or complete graft removal. This study aimed to identify outcomes of unilateral graft limb excision for infected ABFGs and factors predictive of subsequent contralateral or main body graft limb infection.

Methods: A retrospective review of patients treated with unilateral graft limb excision for infection of an isolated limb of an ABFG from 2001 to July 2014 was performed. Endovascular and aortic tube graft infections were excluded. Outcomes were freedom from contralateral graft limb excision, overall survival, and factors predicting subsequent contralateral limb or main body infection.

Results: Fifteen patients underwent unilateral graft limb excision and revascularization for treatment of an infected ABFG isolated to one graft limb. Indications for the original ABFG were aortoiliac occlusive disease in 11 patients and aortoiliac aneurysm in 4 patients. All patients presented with clinical evidence consistent with unilateral graft limb infection and clinical findings confirmed radiographically. Unilateral graft explantation was performed for isolated infrainguinal graft limb infection with no retroperitoneal infection on exploration or if patients were too ill to tolerate total graft explantation despite infection in the retroperitoneum. Seven patients, all of whom underwent initial operation for aortoiliac occlusive disease, developed contralateral limb infection at a median follow-up of 23.2 months after unilateral excision. The remaining eight patients remained free of contralateral graft limb infection at median follow-up of 38.8 months. Patient demographics were similar between the two groups. Factors predictive of contralateral graft limb infection included an ABFG placed for aortoiliac occlusive disease (P = .03) and culture evidence of infection above the inguinal ligament (P = .07; positive predictive value of 71%). Median duration of targeted antibiotic therapy was 42 days, and neither duration of antibiotics nor cultured microorganism predicted recurrent graft infection. Overall mortality was 40% and was similar between patients who developed contralateral or main body graft infection and those who did not. There was no limb loss, and overall median follow-up was 44.7 months.

Conclusions: Isolated unilateral infection of an ABFG limb can be managed with single graft limb excision, provided the infection is isolated to the infrainguinal graft segment. Factors predicting subsequent contralateral or main body graft infection include ABFGs originally placed for aortoiliac occlusive disease and culture-positive graft infection above the inguinal ligament.