Unilateral inline replacement of infected aortofemoral graft limb with femoral vein

From the Society for Clinical Vascular Surgery

Unilateral inline replacement of infected aortofemoral graft limb with femoral vein

Christian D. Simmons, MD,a Ahsan T. Ali, MD,a Kousta Foteh, MD,b Matthew R. Abate, MD,a Matthew R. Smeds, MD,a Horace J. Spencer, BS,a and G. Patrick Clagett, MD,c Little Rock, Ark; Houston, Tex; and Upper Malboro, MD

Abstract

Objective: Aortic graft infection remains a formidable challenge for the vascular surgeon. Traditionally, reconstruction with a neoaortoiliac system (NAIS) involves removal of the entire synthetic graft with in situ reconstruction using femoral vein. Whereas the NAIS procedure is durable with excellent graft patency and a low reinfection rate, it can take up to 10 hours and result in a high perioperative complication rate with significant mortality. Not infrequently, the infection is limited to a single limb. In addition, the patient may be too frail to tolerate aortic clamping for a complete graft excision. Under such circumstances, complete excision of the aortofemoral bypass graft (AFBG) may not be indicated. It is hypothesized that local control of infection and limited reconstruction using femoral vein may be acceptable. The objective of this study was to examine the outcomes of all patients who underwent partial AFBG resection and in situ reconstruction with femoral vein.

Methods: A retrospective review of all AFBG infections from 2003 to 2015 treated at a tertiary care facility was undertaken. Patients who underwent unilateral partial graft excision with inline reconstruction using femoral vein at the distal (femoral) anastomosis were included. Complete excisions with bilateral revascularizations using any conduit or any extraanatomic reconstructions were excluded. The primary end point was successful treatment of infection. Secondary end points were procedure-related mortality, graft patency, and perioperative complications.

Results: During a 12-year period, partial graft excision with bypass using the femoral vein was performed in 21 patients (24 limbs). Mean age was 61 6 12 years. There were 13 men and 8 women. Mean follow-up was 53 6 27 months. Successful treatment was achieved in 19 of 21 patients. The two treatment failures were due to persistent infection. One of these patients declined complete graft excision and is receiving lifelong suppressive antibiotic therapy. The other patient underwent complete graft excision and an NAIS reconstruction. There were no perioperative or procedure-related deaths. There were no major amputations, and primary graft patency was 92% at 72 months. The most common AFBG culture isolate was Staphylococcus species. Approximately one-third of cultures did not yield any growth. Patients underwent anywhere from 1 to 12 weeks of combined intravenous and oral antibiotic therapy.

Conclusions: This limited series demonstrates excellent graft patency with a low persistent infection rate. Thus, in patients with localized graft infection, partial excision with preservation of the proximal synthetic graft is an acceptable alternative when patient factors preclude complete graft excision. (J Vasc Surg 2016;-:1-9.)

Treating an aortofemoral bypass graft (AFBG) infection can be difficult. Although the incidence is low (0.2%-3%), an AFBG infection carries significant morbidity, and the associated mortality can range from 10% up to

From the University of Arkansas for Medical Sciences, Little Rocka; the Herman Memorial Hospital, Houstonb ; and Retired, Upper Malboro.^c
Author conflict of interest: none.
Presented at the Thirty-eighth Annual Symposium of the Society for Clinical Vascular Surgery, Scottsdale, Ariz, April 7-10, 2010.
Correspondence: Ahsan T. Ali, MD, Professor of Surgery, Department of Surgery, 4301 W Markham St, Slot 520-2, Little Rock, AR 72205 (e-mail: sibiahsan@yahoo.comsibiahsan@yahoo.com).
The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
0741-5214
Copyright 2016 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2016.09.051

43%.^1-4 The time interval from the original procedure to diagnosis of graft infection is crucial in decisionmaking while managing an often-complex patient. Early infections (<3 months after surgery) may involve the graft in its entirety because the graft is not yet incorporated. This may necessitate a complete removal.5,6 Late AFBG involvement can occur from catheterization or other systemic infections and may not involve the entire graft.^7-12 The presentation can range from a “mass” in the groin due to a small femoral artery pseudoaneurysm (FAP) to an anastomotic disruption with life-threatening hemorrhage.

The fundamentals of treating any vascular infection entail removal of prosthetic material, preferably in its entirety. Revascularization is achieved through inline or extra-anatomic bypass using either autologous or antibiotic-soaked synthetic graft. Multiple series have been published demonstrating excellent outcomes

with the neoaortoiliac system (NAIS) but with an associated morbidity and mortality of 14% to 20%.6,13,14 Not infrequently, just one limb or groin may be affected, with the infection limited to only the distal (femoral) anastomosis. When evaluating a unilateral AFBG limb infection, the vascular surgeon is faced with the dilemma of whether to replace the entire graft or part of it. The traditional teaching has been removal of the entire graft if there is reasonable suspicion of pangraft infection. However, the patient may be too frail to undergo a complete excision even in the face of entire graft involvement. In this setting, is partial graft replacement feasible? We hypothesized that partial resection of the AFBG with reconstruction using femoral vein (hemi-NAIS) in select patients can be a reasonable alternative to a complete excision. This study represents our institutional experience with the hemi-NAIS procedure.

METHODS

rom 2003 to 2015, all patients with AFBG infection were retrospectively reviewed at the University of Arkansas for Medical Sciences, Little Rock, Arkansas. The Institutional Review Board approved this study. According to Institutional Review Board policy, informed consent from the patients was not required. The diagnosis of AFBG infection was based on clinical presentation in addition to imaging with computed tomography angiography, duplex ultrasound, and occasionally radionuclide scanning. All patients with an AFBG and infection limited to one or both groins were included on an intention-to-treat basis. Patients undergoing complete excision and revascularization were excluded, and these cases have been published previously.6 Similarly, patients with iliofemoral bypasses, femoral-femoral bypasses, endografts, or aortoiliac graft infections were also excluded. Bypasses for any noninfectious etiology, infected pseudoaneurysm, or mycotic aneurysms of the native femoral artery were not included. Medical records were retrospectively reviewed for demographics, clinical presentation, associated comorbidities, vascular laboratory, and procedure-related complications. Data regarding graft microbiology, duration of antibiotic treatment, and incidence of recurrent or persistent infection were recorded. This review was initially presented at the 2010 Society for Clinical Vascular Surgery annual meeting.15 The present work is a continuation of that with long-term follow-up for incidence of recurrent infection.

Surgical technique. By definition, the hemi-NAIS consists of an inline bypass using ipsilateral femoral vein to replace varying lengths of an AFBG limb at the distal anastomosis (Fig 1). If there was evidence of pangraft infection, a complete excision with revascularization (NAIS) was recommended with the caveat that the patient can undergo surgery of this magnitude. However, if

ARTICLE HIGHLIGHTS

Significance: The study assessed the effectiveness of using ipsilateral autologous femoral vein inline to reconstruct infected unilateral aortofemoral bypass graft limbs.
Type of Research: Retrospective single-center cohort study
Take Home Message: Nineteen of 21 patients with aortofemoral graft limb infection treated with unilateral graft limb replacement with autologous ipsilateral femoral vein were free of infection at a mean of 53 months, with a graft patency of 92%.
Recommendation: The authors suggest that reconstruction of unilateral aortofemoral graft limb infections with autologous femoral vein is an effective long-term strategy in selected patients.
Strength of Recommendation: 2. Weak
Level of Evidence: C. Low or very low

Fig. 1 Hemi-neoaortoiliac system (NAIS). The schematic depicts a partial replacement of the right limb of an aortofemoral bypass graft (AFBG) with femoral vein. The main body and contralateral limb of the graft have been preserved.

the infection was localized to one limb or just the distal anastomosis, a hemi-NAIS was planned (Fig 2). The involved limb was exposed through a retroperitoneal approach. Once an adequate length of the involved limb had been exposed, graft incorporation was then

Fig. 2 Algorithm for treatment of aortofemoral bypass graft (AFBG) infection. NAIS, Neoaortoiliac system.

assessed. Lack of incorporation was considered a sign of pangraft infection, and thus a complete excision was considered. However, we took into account whether the patient could undergo surgery of this magnitude, femoral vein diameter, and culture results. If the graft infection was polymicrobial or grew gram-negative or fungal organisms, a complete excision was recommended. Femoral vein diameter had to be 6 mm or larger with adequate length throughout. If the patient was at prohibitive risk for a complete excision, we proceeded with a hemi-NAIS.

After exposure, the proximal AFBG limb was controlled with silastic loops. An adequate length of the ipsilateral femoral vein (10-25 cm) was then exposed through a separate incision with ligation of side branches. After this, the infected femoral anastomosis was dissected out. The previously exposed limb was then excised. All instruments and gowns and gloves were changed to minimize cross-contamination. The femoral vein graft was harvested, and valves were ablated through eversion or valvulotome. The orientation of the vein graft was always reversed with the distal anastomosis sewn first so that the entire length of the vein could be used. Finally, the proximal anastomosis was performed in an end-to-end fashion with the proximal limb/body of the AFBG. Surgical instruments and

gowns and gloves were changed again for the proximal anastomosis. A small (0.5-1.0 cm) section of remaining proximal graft was sent for Gram stain and culture as a separate specimen. If there was skin necrosis, a sinus track, or a soft tissue defect overlying the femoral anastomosis, a muscle flap was used for coverage. Our muscle flap of choice was the gracilis and, infrequently, the sartorius muscle. In select patients (six), the dissection was carried out through a single groin incision, and a limited 8 to 10 cm of the distal AFBG limb was replaced. These patients did not have a retroperitoneal approach.

Initial antimicrobial therapy consisted of broad-based coverage that included antibiotics to treat methicillinresistant Staphylococcus aureus (MRSA) as well as fungal organisms. The antimicrobial coverage was then adjusted according to culture results whenever possible. Patients with no growth identified from cultures had an empirical course of antibiotics that ranged from 7 to 10 days. Patients with polymicrobial or multidrug-resistant infections were initially treated with a course of intravenous antibiotics and then transitioned to oral antibiotics at the surgeon’s discretion.

Postoperative graft surveillance using vascular laboratory was performed every 3 months during the first year and every 6 months thereafter. Patency (primary

Table I.Demographics and outcomes

Demographics

No. of patients 21
No. of limbs treated 24
Age, years 61.4 +/- 12.2
Men:women 13:8
Unilateral:bilateral 18:3
ASA class 3.5 +/- 0.6
Muscle flaps 13
Emergent 8
Length of stay, days
ICU 2.8 +/- 2.1
Total 5.6 +/- 2.7
Presentation
Groin infection 5
Hemorrhage/groin infection 3
FAP 11
Ischemia 5
Microbiology
No growth 8
Unimicrobial 13
Polymicrobial 3
Periprocedural complications
Fasciotomies 1a
Atrial fibrillation 1
Persistent graft infection 2
Acute kidney injury 3

ASA, American Society of Anesthesiologists; FAP, femoral artery pseudoaneurysm; ICU, intensive care unit. Continuous data are reported as means 6 standard deviation.

*Fasciotomy was performed for compartment syndrome before vein harvest.

and secondary) and limb salvage data were defined according to the reporting standards of the Society for Vascular Surgery.16 The primary end point was complete cure of local graft infection. Secondary end points were graft patency, limb salvage, and infection-free survival. Survival data were assessed through clinic visits and telephone calls.

Means and standard deviations were used to summarize continuous data, whereas counts were used to present categorical information. Time-to-event outcomes, such as graft patency and patient survival, were summarized using Kaplan-Meier methodology. These analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC) and R version 3.2.4 (R Foundation for Statistical Computing, Vienna, Austria).

RESULTS

From 2003 to 2015, there were 21 patients (24 limbs) who underwent partial excision and inline reconstruction of infected AFBG limbs using the ipsilateral femoral vein (hemi-NAIS). Nineteen of the 21 patients had undergone AFBG for occlusive disease. Mean age was 61 +/- 12 years. There was no procedure-related or inhospital death. Mean follow-up was 53 +/- 27 months (range, 12-110). The most common organism was S. aureus (38%), and no growth was seen in 33% of specimen cultures. Three patients had bilateral limb replacements with preservation of the main graft body (Table I). Each bypass was performed on a separate occasion. Average hospital length of stay was 5.6 +/- 2.7 days, and the average intensive care unit stay was 2.8 +/- 2 days.

There were two treatment failures. One patient (No. 13), a 48-year-old man, subsequently required complete graft excision. He had undergone an AFBG for occlusive disease at another facility. He had two episodes of graft disruption despite replacement of the right distal limb with rifampin-soaked Dacron. We performed a hemiNAIS procedure emergently using ipsilateral femoral vein. The original graft, as expected, was not incorporated. The proximal graft, left in situ, grew Pseudomonas aeruginosa and Bacteroides fragilis (Table II). He was also severely immunocompromised from a recent bout of chemotherapy and steroids. Eight weeks later, we removed the entire graft and revascularized with the femoral vein (NAIS). During this time, he was treated with intravenous culture-specific antimicrobial therapy. The second patient (No. 11; Table II) represents a special case of known, persistent graft infection. At 83 years old, she underwent replacement of the right distal anastomosis for ischemia and elevated velocities on duplex ultrasound scan. Intraoperative cultures were positive for Enterococcus faecalis. The proximal graft was not incorporated, and purulence was present. A pangraft infection was suspected. Despite our recommendation for a complete graft excision, the patient refused any further intervention. After completing 6 weeks of intravenous antibiotic therapy, she was transitioned to lifelong oral antibiotics. She continues to refuse surgery and has done reasonably well during the course of 40 months of follow-up.

Another patient (No. 3) did not require complete excision. She was a 44-year-old woman who had undergone an AFBG 4 weeks before presentation. She had hemorrhage from one of the femoral anastomoses. A partial replacement of the involved limb was performed using femoral vein. As expected, the proximal graft was not incorporated but did not grow out any organism from the proximal graft left in situ. The femoral anastomosis tissue culture grew MRSA. She received intravenous antibiotics for 4 weeks and then transitioned to oral antibiotics for an additional 8 weeks after surgery. A complete NAIS was planned but never performed. She remains clinically infection free to date at 110 months after surgery. There were two patients (patients No. 5 and No. 10) who had femoral vein graft thrombosis at 15 and 77 months, respectively, after surgery. Patient No. 5 had a successful

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thrombectomy, whereas patient No. 10 underwent femoral-femoral bypass with a synthetic graft.

Overall survival is depicted in Fig 3, and graft patency is depicted in Fig 4. During the mean follow-up period of 53 months, there were a total of four deaths ranging from 6 to 77 months after surgery. None of the deaths were from graft-related issues. There was no procedurerelated mortality. There was no incidence of graft reinfection or persistent infection other than in the patients mentioned before. There was one case in which a fasciotomy was done (patient No. 14; Table II); however, this was before the femoral vein harvest. She had ischemia-reperfusion syndrome, and after initial graft thrombectomy of her AFBG limb, she required ipsilateral four-compartment fasciotomy. Because of clinical infection, we electively performed a hemi-NAIS a few days later.

DISCUSSION

Treating any vascular graft infection can be complicated. The AFBG infection can be challenging as it involves removal of graft from the abdomen as well as from both groins. These patients usually have advanced vascular disease. Not infrequently, they have been undergoing prolonged hospitalizations and can be severely immunocompromised or nutritionally depleted.

Traditionally, the dictum has been to remove the graft in its entirety if there is evidence of pangraft infection. A new bypass is attempted through a noninfected (extraanatomic) field. The standard axillofemoral graft evolved when staging of the procedure was found to be more tolerable and also made intuitive sense as first described by Reilly et al.1 Despite staging, the procedure-related mortality remained around 20% in the best of hands.^1,4,17 Recently, there has been a trend toward inline replacement over extra-anatomic reconstruction. Available conduits are the femoral vein, cryopreserved vein, and synthetic ones, such as antibiotic-soaked Dacron graft.^6,18,19 Neoaortoiliac reconstruction with femoral vein (NAIS) has excellent durability, resistance to reinfection, and superb long-term patency.⁶ However, the procedure is time-consuming (8-10 hours) and labor-intensive. Cryopreserved homografts are also widely available, although there is significant added cost. They have their own unique set of conduit-specific complications, from early restenosis to aneurysmal degeneration in up to 23% to 30% of the patients. Oderich et al demonstrated a recurrent or persistent infection rate of up to 17% when using rifampin-soaked Dacron grafts with low overall mortality.²⁰ However, the majority of the patients in their series had aortic graft infections limited to the abdomen, with very few replacements for occlusive disease involving both femoral anastomoses. For a graft infection in the groin with skin and soft tissue involvement and limited outflow through the profunda femoris artery, we believe that the femoral vein is the best possible conduit.^13,15,21,22

Bell et al have demonstrated excellent durability for the femoral vein in treatment of infected FAPs.⁷ In their series, 10 of 11 patients with infected FAP were treated with either obturator or “extra-anatomic” bypasses using femoral vein. The extra-anatomic bypasses were in the same vicinity but were more “lateral” than in situ. Although the distal anastomosis was in the same surgical field, they did not encounter any recurrent infection and had excellent patency. Our series is similar to theirs with the exception that we did not make any attempt to use extra-anatomic bypasses. All bypasses were in situ even in the presence of severe infection. However, we did use muscle flaps frequently as an adjunct for soft tissue coverage.²³

Although our approach for treating unilateral AFBG infection is similar to that of Crawford et al in concept of graft preservation and autogenous conduit,⁸ it differs on several accounts. Their method of revascularization is extra-anatomic with femoral-femoral bypass, whereas in our series, the approach has been in situ replacement. The incidence of persistent residual infection in the contralateral groin or proximal graft infection has remained very low, at least clinically. Theoretically, the proximal graft and main body were at risk of becoming infected as both the proximal and distal anastomoses shared the same surgical field. However, we did not observe an increased incidence of contralateral groin or proximal graft infection. In fact, we believe that patients 1, 6, and 12 (Table II) could very well have had infection of the entire graft at the time of the hemiNAIS. These patients, however, have been symptom free after more than 50, 87, and 50 months of followup, respectively. To date, there has been no recurrent or persistent infection in this series other than in the patients mentioned before (Table II) with a mean followup of 53 months. The antibiotic regimen included coverage for gram-positive (including MRSA), gramnegative, and fungal organisms. Patients with no growth underwent broad-spectrum antibiotic coverage for 7 to 10 days. Others, especially in the setting of resistant or polymicrobial infections, required longer antibiotic therapy (Table II).

Calligaro et al initially introduced the concept of partial graft removal and thereby challenged the dogma of entire graft excision.²⁴ Their series spanning >20 years included 14 patients for whom selective graft replacement was, at least initially, successful. It is noteworthy that partial graft excision with replacement with prosthetic was indicated for “less virulent” organisms. Longterm treatment failures, however, were not reported with partial graft excision. Nonetheless, it was a nontraditional concept of partial graft preservation in high-risk patients. Our study is similar in that the majority of patients had occlusive disease. The runoff was a single profunda femoris artery in most cases, and a significant number of patients were considered high risk. The

Table II.Patient data

Patient No.	Age/sex	Type of disease	Time since AFBG	Presentation	Muscle flap
1	63/F	Aneurysmal	120	FAP	None
			121		None
2	76/F	Occlusive	60	Groin infection	None
3	44/F	Occlusive	1	Hemorrhage, groin infection	Gracilis
4	47/M	Occlusive	84	FAP	None
5	49/M	Occlusive	10	Ischemia	None
6	76/M	Occlusive	128	FAP	None
	75/M		120		Gracilis
7	52/M	Occlusive	27	Ischemia	-
8	69/M	Occlusive	108	Groin infection	Gracilis
9	51/M	Occlusive	8	Ischemia, groin infection	Gracilis
10	50/M	Occlusive	16	FAP	Sartorius
11	83/F	Occlusive	144	Groin infection	Gracilis
12	72/M	Aneurysmal	-	FAP	-
					Sartorius
13	48/M	Occlusive	2	Hemorrhage, groin infection	Gracilis
14	44/F	Occlusive	36	Ischemia, groin infection	Gracilis
15	56/M	Occlusive	36	FAP	None
16	66/F	Occlusive	8	Groin infection	None
17	71/M	Occlusive	132	Hemorrhage, groin infection	Gracilis
18	60/M	Occlusive	12	Groin infection	Sartorius
19	70/M	Occlusive	31	FAP	Gracilis
20	52/F	Occlusive	120	Ischemia	Gracilis
21	66/F	Occlusive	264	FAP	Gracilis

AFBG, Aortofemoral bypass graft; FAP, femoral artery pseudoaneurysm; IV, intravenously; MRSA, methicillin-resistant Staphylococcus aureus; PO, orally.Details of each patient, presentation, duration of antibiotics, status of the graft, patency, and persistent infection.

mean American Society of Anesthesiologists score in our series was 3.5 (Table I).

It can be argued justifiably that patient No. 13 should have had a complete NAIS from the outset. However, he presented with an anastomotic disruption and was in septic shock. Partial replacement with femoral vein allowed him to be stabilized before undergoing a complete excision. Thus, limited replacement of the AFBG limb with femoral vein served as a bridge to complete resection. He has remained symptom free for 41 months now.

The intent of this study is not to endorse the hemi-NAIS over a complete NAIS if the patient is able to tolerate the procedure. However, hemi-NAIS may be sufficient for patients with a localized infection (with no evidence of contralateral or proximal limb infection) due to less virulent organisms. Furthermore, this approach does not preclude a full excision at a later date. If a future,

complete NAIS reconstruction is contemplated, we recommend using at least 20 to 25 cm of femoral vein and replacement of the entire limb during the hemi-NAIS procedure. This would allow the proximal anastomosis to be accessed during the abdominal part of a future NAIS procedure. Thus, one can avoid groin re-exploration. We also believe that subtotal femoral vein harvest could result in lower venous morbidity than with a complete length excision. We had only one patient requiring fasciotomy, and that too was before the vein harvest.

There are no guidelines regarding graft length or type for partial limb replacement. This series demonstrates a limited in situ replacement of infected AFBG limbs with ipsilateral femoral vein, the hemi-NAIS. Our algorithm is outlined in Fig 2. If the entire graft is clinically infected, a complete excision and NAIS reconstruction is recommended. If the graft is not infected proximally

Table II. Continued.

	Antibiotic, weeks
Microbiology	IV	PO	Intraoperative assessment of proximal graft	Graft status	Infection-free survival, months
No growth	1	7	Left: incorporated	Patent	50
Enterococcus faecalis	1	7	Right: not incorporated	Patent	50
No growth	1	12	Not incorporated	Patent	30
MRSA	1	2	Not incorporated	Patent	110
Staphylococcus aureus	1	-	Incorporated	Patent	49
Staphylococcus epidermidis	1	12	Incorporated	Thrombosed	77
No growth	1	12	Not incorporated	Patent	87
No growth	1	1.5	Not incorporated	Patent	94
MRSA	1	-	Not incorporated	-	80
MRSA	1	4	Incorporated	-	74
MRSA, Serratia	1.5	6	Not incorporated	Patent	77
Pseudomonas aeruginosa	1	10	-	Thrombosed	37
Enterococcus faecalis	6	Lifelong	Not incorporated	Patent	40
MRSA	1	-	Right: incorporated	-	42
MRSA	1	2.5	Left: not incorporated	-	50
Pseudomonas aeruginosa, Bacteroides fragilis, Enterococcus	6	2	Not incorporated	Patent	41
No growth	1	-	Incorporated	Patent	18
No growth	1	-	Incorporated	Patent	55
Klebsiella, Morganella	3	8	Not incorporated	Patent	70
Staphylococcus epidermidis	1	2	Incorporated	Patent	70
Staphylococcus aureus	1	2.5	Incorporated	Patent	28
Skin flora	1	1.5	Incorporated	Patent	10
No growth	2	6	Incorporated	Patent	12
No growth	1	1.5	Incorporated	Patent	14

and is well incorporated, a hemi-NAIS is planned. If the graft is not incorporated and the patient is medically at high risk, a partial replacement is undertaken with prolonged postoperative antibiotics. We do realize that some degree of cross-contamination is impossible to avoid. However, when the infected material has been removed, we change gowns and gloves and use a second set of instruments. This approach is recommended for replacement of a single limb for local infection control, is well tolerated, and may offer the most practical option for a frail patient. Moreover, the hemi-NAIS can even serve as a staging procedure for a complete NAIS. This is the largest series of its kind in which the synthetic graft has been preserved with revascularization using autogenous conduit. Although the series does not have a large cohort, the AFBG limb was not incorporated (at least according to the operative note) in nine patients. This subgroup included three

patients with bilateral involvement who may have had a low-grade pangraft infection. Despite this, the majority (78%) of the nonincorporated grafts subgroup has done well with no clinical evidence of ongoing infection. They may still require a future complete NAIS, but for now, they have been symptom free.

This study has several shortcomings. This is a singlecenter retrospective review with a small number of patients. Patient No. 13, who had pangraft infection and underwent a hemi-NAIS, may be an exception. The degree of graft “incorporation” can be subjective and based on the surgeon’s “intuition” as well as his or her experience in dealing with graft infections

CONCLUSIONS

We believe that in select patients with localized infection involving a single limb, the graft can be salvaged with partial excision and replacement with the femoral vein. In this

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Fig. 3 Kaplan-Meier survival curve for all patients. The dotted line indicates that standard error exceeds 10%.

Fig. 4 Kaplan-Meier curve for primary vein graft patency. The dotted line indicates that standard error exceeds 10%.

setting, with the proven durability and patency of the femoral vein and adjunctive use of muscle flaps,²³ an extra-anatomic bypass may not be necessary. If the patient can tolerate a complete excision, an NAIS reconstruction is recommended, provided there is evidence of pangraft infection. We also recommend an NAIS reconstruction if polymicrobial infection due to gram-negative or fungal organisms has been identified. However, the fragility of the patient may not allow an NAIS reconstruction. Thus, hemi-NAIS may be the most practical option.

AUTHOR CONTRIBUTIONS

Conception and design: AA, KF
Analysis and interpretation: AA, HS, PC
Data collection: CS, AA, KF, MA
Writing the article: CS, AA, KF
Critical revision of the article: CS, AA, MS, PC
Final approval of the article: CS, AA, KF, MA, MS, HS, PC
Statistical analysis: HS
Obtained funding: AA
Overall responsibility: AA

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CS and AA contributed equally to this article and share co-first authorship.

REFERENCES

Reilly LM, Stoney RJ, Goldstone J, Ehrenfeld WK. Improved management of aortic graft infection: the influence of operation sequence and staging. J Vasc Surg 1987;5:421-31.
Quinones-Baldrich WJ, Hernandez JJ, Moore WS. Long-term results following surgical management of aortic graft infection. Arch Surg 1991;125:507-11.
O’Hara PJ, Hertzer NR, Beven EG, Krajewski LP. Surgical management of infected abdominal aortic grafts; review of a 25-year experience. J Vasc Surg 1986;3:725-31.
Moulton S, Adams M, Johansen K. Aortoenteric fistula. A 7 year urban experience. Am J Surg 1986;151:607-11.
Modrall JG, Clagett GP. The role of imaging techniques in evaluating possible graft infections. Semin Vasc Surg 1999;12: 339-47.
Ali A, Modrall JG, Hocking J, Valentine JR, Spencer H, Eidt JF, et al. Long-term results of the treatment of aortic graft infection by in situ replacement with femoral popliteal vein grafts. J Vasc Surg 2009;50:30-9.
Bell CL, Ali AT, Brawley JG, D’Addio VJ, Modrall JG, Valentine RJ, et al. Arterial reconstruction of infected femoral artery pseudoaneurysms using superficial femoral-popliteal vein. J Am Coll Surg 2005;200:831-6.
Crawford JD, Landry GJ, Moneta GL, Mitchell EL. Outcomes of unilateral graft limb excision for infected aortobifemoral graft limb. J Vasc Surg 2016;63:407-13.
Benjamin ME, Cohn EJ, Purtill WA, Hanna DJ, Lilly MP, Flinn WR. Arterial reconstruction with deep leg veins for the treatment of mycotic aneurysms. J Vasc Surg 1999;30: 1004-15.
Padberg F, Hobson R, Lee B, Anderson R, Manno J, Breitbart G, et al. Femoral pseudoaneurysm from drugs of abuse: ligation or reconstruction? J Vasc Surg 1992;15:642-8.
Hollis H, Rehring T. Femoral endarteritis associated with percutaneous suture closure: new technology, challenging complications. J Vasc Surg 2003;38:83-7.
Cherr GS, Travis JA, Ligush J, Plonk G, Hansen KJ, Braden G, et al. Infection is an unusual but serious complication of a femoral artery catheterization site closure device. Ann Vasc Surg 2001;15:567-70.
Ali A, McLeod N, Kalapatapau VR, Moursi MM, Eidt JF. Staging the neoaortoiliac system: feasibility and short term outcomes. J Vasc Surg 2008;48:1125-30; discussion: 1130-1.

Clagett GP, Valentine RJ, Hagino RT. Autogenous aortoiliac/ femoral reconstruction from superficial femoral-popliteal veins: feasibility and durability. J Vasc Surg 1997;25:255-66; discussion: 267-70.
Foteh K, Kalapatapu V, Eidt JF, Waheed A, Moursi M, Ali AT. Partial aortic graft excision with in-situ bypass using femoral vein. Presented at the poster session of the Thirty-eighth Annual Meeting of the Society for Clinical Vascular Surgery; Scottsdale, AZ; April 7-10, 2010.
Rutherford RB, Baker JD, Ernst C, Johnson KW, Porter JM, Ahn S, et al. Recommended standards for reports dealing with lower extremity ischemia. J Vasc Surg 1997;26:517-38.
Seeger JM, Pretus HA, Welborn MB, Ozaki CK, Flynn TC, Huber TS. Long-term outcome after treatment of aortic graft infection with staged extra-anatomic bypass grafting and aortic graft removal. J Vasc Surg 2000;32:451-9; discussion: 460-1.
Kieffer E, Gomes D, Chiche L, Fleron MH, Koskas F, Bahnini A. Allograft replacement for infrarenal aortic graft infection: early and late results in 179 patients. J Vasc Surg 2004;39: 1009-17.
Harlander-Locke MP, Harmon LK, Lawrence PF, Oderich GS, McCready RA, Morasch MD, et al. The use of cryopreserved aortoiliac allograft for aortic reconstruction in the United States. J Vasc Surg 2014;59:669-74.
Oderich GS, Bower TC, Cherry KJ Jr, Panneton JM, Sullivan TM, Noel AA, et al. Evolution from axillofemoral to in situ prosthetic reconstruction for the treatment of aortic graft infections at a single center. J Vasc Surg 2005;43: 1166-74.
Clagett GP, Bowers BL, Lopez-Viego MA, Rossi MB, Valentine RJ, Myers SI, et al. Creation of a neo-aortoiliac system from lower extremity deep and superficial veins. Ann Surg 1993;218:239-48; discussion: 248-9.
Modrall JG, Hocking JA, Timaran CH, Rosero EB, Arko FR, Valentine RJ. Late incidence of chronic venous insufficiency after deep vein harvest. J Vasc Surg 2007;46:520-5.
Ali AT, Rueda M, Desikan S, Moursi M, An R, Spencer H, et al. Outcomes after retroflexed gracilis muscle flap for vascular infections in the groin. J Vasc Surg 2016;64:452-7.
Calligaro KD, Veith FJ, Yuan JG, Gargiulo NJ, Dougherty MJ. Intra-abdominal aortic graft infection: complete or partial graft preservation in patients at very high risk. J Vasc Surg 2003;38:1199-205.

Submitted Jul 25, 2016; accepted Sep 21, 2016.

Unilateral inline replacement of infected aortofemoral graft limb with femoral vein

Summary