Cadaveric aorta implantation for aortic graft infection

Abstract

This case report describes a 73-year-old gentleman who underwent explantation of an infected prosthetic aorto-iliac graft and replacement with a cryopreserved thoracic and aorto-iliac allograft. The patient has been followed up a for more than a year after surgery and remains well. After elective tube graft repair of his abdominal aortic aneurysm (AAA) in 2003, he presented to our unit in 2012 in cardiac arrest as a result of a rupture of the distal graft suture line due to infection. After resuscitation he underwent aorto-bifemoral grafting using a cuff of the original aortic graft proximally. Distally the new graft was anastomosed to his common femoral arteries, with gentamicin beads left in situ. Post discharge the patient was kept under close surveillance with serial investigations including nuclear scanning, however it became apparent that his new graft was infected and that he would require aortic graft replacement, an operation with a mortality of at least 50%. The patient underwent the operation and findings confirmed a synthetic graft infection. This tube graft was explanted and a cryopreserved aorta was used to the refashion the abdominal aorta and its bifurcation. The operation required a return to theatre day one post operatively for a bleeding side branch, which was repaired. The patient went on to make a full recovery stepping down from the intensive therapy unit day 6 post operatively and went on to be discharged 32 days after his cryopreserved aorta implantation.

Keywords: Aortic graft; Cadaveric aorta; Infection; Transplant; Vascular surgery.

Fig. 1

CT Angiogram May 2013: a large complex fluid collection arising from the region of the aorto-bifemoral graft extending to the left iliac region measures approximately 10 × 8 cm. The left ureter is obstructed by the pelvic fluid collection with a mild left hydronephrosis.

Fig. 2

NM White Cell HMPAO Whole body Technecium 99-m July 2013: the fused co-registered images show that the left psoas collection around the aortic graft demonstrates no abnormal uptake suggestive of periprosthetic infection.

Fig. 3

CT Guided Aspiration August 2013: right lateral position. Puncture of peri-graft collection. Haematoma aspirated. There was some reduction in the volume of low-density within the collection post aspiration.

Fig. 4

CT Angiogram October 2013: considerable increase in size of the left retroperitoneal collection/haematoma which now extends to the groin and the level of the diaphragm. Worsening of the marked left hydronephrosis, the AP diameter of the left renal pelvis now measures 3 cm.

Fig. 5

NM Dynamic imaging following radiolabelled red cell injection October 2013: no abnormal tracer relation is seen suggestive of a haemorrhagic leak around the site of the psoas collection and left groin.

Fig. 6

Bilateral Ureteric Stenting January 2014.

Fig. 7

CryoLife Cryopreserved aorta. Descending aorta and aortoiliac components anastomosed in preparation for transplantation.

Fig. 8

CT Angiogram April 2014: There is a critical stenosis at the left groin anastomosis and the collection associated with the graft is smaller.