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• W2381300960 abstract "A 65-year-old man presented with an infected perivisceral aortic aneurysm after previous treatment of an abdominal aortic aneurysm with an endograft. On presentation, he was septic and had occlusion of the celiac, superior mesenteric, inferior mesenteric, and bilateral renal arteries. He underwent a three-stage procedure: first, axillobifemoral bypass; then resection of the thoracoabdominal aorta; and finally bypass from the ascending aorta to the celiac and superior mesenteric arteries with a rifampin-soaked Gelsoft graft (Vascutek, Renfrewshire, Scotland). The abdominal pain resolved, and the patient remains symptom free 10 months postoperatively. This rare surgical revascularization technique offered a nontraditional solution to a difficult surgical issue. A 65-year-old man presented with an infected perivisceral aortic aneurysm after previous treatment of an abdominal aortic aneurysm with an endograft. On presentation, he was septic and had occlusion of the celiac, superior mesenteric, inferior mesenteric, and bilateral renal arteries. He underwent a three-stage procedure: first, axillobifemoral bypass; then resection of the thoracoabdominal aorta; and finally bypass from the ascending aorta to the celiac and superior mesenteric arteries with a rifampin-soaked Gelsoft graft (Vascutek, Renfrewshire, Scotland). The abdominal pain resolved, and the patient remains symptom free 10 months postoperatively. This rare surgical revascularization technique offered a nontraditional solution to a difficult surgical issue. Chronic mesenteric ischemia (CMI) remains a challenging problem despite a variety of revascularization methods. Whereas endovascular stenting has become more common as a first-line therapy, it is not always an option because of anatomic constraints.1Atkins M.D. Kwolek C.J. LaMuraglia G.M. Brewster D.C. Chung T.K. Cambria R.P. Surgical revascularization versus endovascular therapy for chronic mesenteric ischemia: a comparative experience.J Vasc Surg. 2007; 45: 1162-1171Abstract Full Text Full Text PDF PubMed Scopus (166) Google Scholar, 2Fioole B. van de Rest H.J. Meijer J.R. van Leersum M. van Koeverden S. Moll F.L. et al.Percutaneous transluminal angioplasty and stenting as first-choice treatment in patients with chronic mesenteric ischemia.J Vasc Surg. 2010; 51: 386-391Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar, 3Arya S. Kingman S. Knepper J.P. Eliason J.L. Henke P.K. Rectenwald J.E. Open mesenteric interventions are equally safe as endovascular interventions and offer better midterm patency for chronic mesenteric ischemia.Ann Vasc Surg. 2016; 30: 219-226Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Open surgical approaches include antegrade bypass from the supraceliac abdominal and thoracic aorta or retrograde bypass from the iliac arteries.4Mateo R.B. O'Hara P.J. Hertzer N.R. Mascha E.J. Beven E.G. Krajewski L.P. Elective surgical treatment of symptomatic chronic mesenteric occlusive disease: early results and late outcomes.J Vasc Surg. 1999; 29 (discussion: 832): 821-831Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar On occasion, the inflow takeoff may not be available for surgical anastomosis, necessitating alternative strategies.5Farber M.A. Carlin R.E. Marston W.A. Owens L.V. Burnham S.J. Keagy B.A. Distal thoracic aorta as inflow for the treatment of chronic mesenteric ischemia.J Vasc Surg. 2001; 33 (discussion: 287-8): 281-287Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 6Chiche L. Kieffer E. Use of the ascending aorta as bypass inflow for treatment of chronic intestinal ischemia.J Vasc Surg. 2005; 41: 457-461Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 7Karkos C.D. McMahon G.S. Markose G. Sayers R.D. Naylor A.R. Axillomesenteric bypass: an unusual solution to a difficult problem.J Vasc Surg. 2007; 45: 404-407Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar This case highlights the rare use of a bypass originating from the ascending aorta in the setting of CMI and an infected aorta. The patient consented to use of his data in this article. He is a 65-year-old man who presented in October 2014 to an outside facility with abdominal pain and pyuria. He was found to have shortness of breath with diastolic heart failure and acute renal failure and was started on hemodialysis. Further imaging and workup demonstrated atheroembolic kidney disease on biopsy and a 5-cm infrarenal abdominal aortic aneurysm as a possible source. Bilateral renal arteries were presumably occluded at this point, leading to his dialysis requirement. He underwent treatment with a Gore modular graft and left iliac artery extension limb (W. L. Gore & Associates, Flagstaff, Ariz). No specific notes were made of perioperative antibiotic treatment. His postoperative course was uneventful. Two months later, he was readmitted to the outside hospital with weakness, fever, chills, and methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia. He was treated with appropriate antibiotics but had continued abdominal and back pain. Subsequent tagged white blood cell scan showed significant uptake in the previously placed endovascular aneurysm repair (EVAR) graft, although no other sources were found. Computed tomography angiography (CTA) revealed a 5.3-cm perivisceral aneurysm proximal to the previously placed graft; inflammatory changes extending into the thoracic aorta; and occlusion of the celiac, superior mesenteric (SMA), and inferior mesenteric arteries and both renal arteries (Fig 1). The kidneys were atrophic. Extensive collaterals from the internal iliac arteries supplied the mesenteric blood flow. He was transferred to Yale-New Haven Hospital. He was also noted to have a 20-pound weight loss. Diagnosis at this time was made of an infected EVAR graft and new, rapidly expanding infected perivisceral aortic aneurysm. Blood cultures on admission again grew MSSA, consistent with the speciation and sensitivities reported from the outside hospital. Echocardiography demonstrated no vegetations suggestive of endocarditis. Further infectious workup also showed no other apparent sources for the seeding of the EVAR graft. He was prepared for a multistage operation with axillobifemoral bypass, followed by resection of the aorta, explantation of the stent graft, and mesenteric revascularization if necessary. The sequence of treatment started with a right axillobifemoral bypass graft. Five days later, he underwent stage two, with a retroperitoneal thoracoabdominal incision. The left renal artery was chronically occluded; therefore, a left nephrectomy was performed to facilitate exposure. The aorta was resected from the iliacs to the lower chest, where a normal-appearing aorta facilitated sutures to oversew the aorta. Visceral branch vessels were all sacrificed, given their likely chronic occlusion based on the patient's extensive collateral network. Preoperative CTA did identify a small-caliber artery of Adamkiewicz at the L1-L2 level, and this was sacrificed. Although it is our practice to place a spinal drain preoperatively for similar clinical situations, given the patient's ongoing infection and sepsis, in this case a spinal drain was not placed. There were no later complications of spinal cord ischemia. The endograft and limbs were removed and both common iliac arteries oversewn. The endograft and aortic tissue were sent for culture but grew no organisms. Doppler interrogation of the antimesenteric border of the small bowel and large bowel as well as of the splenic artery found adequate signals, indicating that his tenuous collateral circulation was still intact, so he was closed. The patient's postoperative course was complicated by respiratory failure, reintubation, and eventual tracheostomy. During the recovery period, he remained malnourished and unable to tolerate tube feeds because of ileus and abdominal pain. Total parenteral nutrition was continued during this time. Because of failure to thrive and to progress, 4 weeks after the second operation, he returned to the operating room for an ascending aorta to hepatic artery and SMA bypass with a 14- × 7-cm rifampin-soaked Gelsoft graft (Vascutek, Renfrewshire, Scotland). The ascending aorta was exposed after a median sternotomy; the abdomen was opened through a continued midline incision, the hepatic artery and SMA were dissected, and a retropancreatic tunnel was created. A tunnel was then created at the posterior diaphragm just anterior and approximately 6 cm to the right of the crus for the graft to traverse from the thoracic cavity into the abdominal cavity (Fig 2). The aorta was clamped using a side-biting clamp after 10,000 units of unfractionated heparin administration. No cardiopulmonary bypass was used. Intraoperative transesophageal echocardiography was used in this case as standard of care to assess the ascending aorta before clamping. The proximal anastomosis was created in an end-to-side fashion off the ascending aorta on the right side; both graft limbs were then brought through the diaphragm and anastomosed to the hepatic artery and SMA. The bowel immediately appeared pink, but the gallbladder was distended and severely inflamed, so a cholecystectomy was performed. Total parenteral nutrition was continued for nutritional support, and later he had a percutaneous gastric tube placed. Chronic antibiotic therapy was continued for life. Three months after the first operation, he was discharged to a rehabilitation facility having normal bowel function. CTA performed just before discharge showed that all grafts were patent (Fig 3). One year postoperatively, he lives at home with support from his family, remains free of abdominal pain, and tolerates oral intake. His weight has increased from 56 kg on his initial presentation to 60 kg on most recent follow-up. He remains on dialysis, but he was able to tolerate the additional surgery of an upper extremity arteriovenous fistula creation for permanent access. Duplex ultrasound and CTA studies showed patent mesenteric and axillobifemoral bypass grafts, with no stenosis. He has been maintained on daily aspirin (81 mg) for graft patency. This case illustrates an uncommon presentation of mesenteric ischemia with occlusion of all native visceral vessels due to infection. It further demonstrates the challenges in finding an inflow source, with an unusual bypass from the uninfected ascending thoracic aorta to the mesenteric vasculature. The patient's initial CTA showed total occlusion of the celiac artery, SMA, and inferior mesenteric artery as well as of the bilateral renal arteries and a network of collaterals from his internal iliac arteries. Whereas this collateral network marginally supplied the patient's visceral organs, it was not enough for long-term viability, particularly in the face of infection. Multiple revascularization options could have been considered, including retrograde bypass from the patient's iliac arteries being fed by his axillobifemoral bypass to his mesenteric arteries to avoid exposing him to median sternotomy. However, this would not provide high-pressure inline flow to his mesenteric vessels and not lend itself to long-term patency. A combined bypass from the ascending aorta to the mesenteric vessels as well as the iliacs for lower extremity perfusion with ligation of the axillobifemoral graft was also a possibility. The patient's axillobifemoral bypass, though, was working well for more than a month at this time, and its removal for an untested combined aorta-iliac-mesenteric bypass would not be ideal. Maintenance of these two separate pathways for lower extremity flow and mesenteric flow preserves options for contingent flow and revascularization in the event of a future issue with either graft. One may also have considered immediate revascularization of the viscera at the time of aortic explantation; however, this was not performed because of the adequate visceral Doppler signals found at the time of explantation and to avoid placing an additional graft in an infected field. There are three reports of using the left subclavian-axillary artery as inflow for an extra-anatomic axillomesenteric bypass graft in the setting of descending thoracic and abdominal aortic occlusion.7Karkos C.D. McMahon G.S. Markose G. Sayers R.D. Naylor A.R. Axillomesenteric bypass: an unusual solution to a difficult problem.J Vasc Surg. 2007; 45: 404-407Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 8Sparks F.C. Ramp J.M. Imparato A.M. Axillo-mesenteric bypass for acute mesenteric infarction.Vasc Surg. 1974; 8: 90-94PubMed Google Scholar, 9Hivet M. Jouan F. Jega A. [Revascularisation of the arteries of the digestive tract by retrosternal bypass from the left subclavian artery (author's transl)].Nouv Presse Med. 1978; 7: 1109-1111PubMed Google Scholar However, especially in light of the patient's infected aorta and right axillobifemoral bypass graft, we opted to pursue more definitive inflow from the ascending aorta. Farber et al reported excellent survival, symptom alleviation, and patency in a series of 18 antegrade revascularizations using the distal thoracic aorta as inflow for CMI.5Farber M.A. Carlin R.E. Marston W.A. Owens L.V. Burnham S.J. Keagy B.A. Distal thoracic aorta as inflow for the treatment of chronic mesenteric ischemia.J Vasc Surg. 2001; 33 (discussion: 287-8): 281-287Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar However, in this case, the infected thoracic aorta was not an option. Therefore, the ascending aorta was the best option for inflow. Because there was concern for potentially infecting the chest, this was delayed as long as possible. Chiche and Kieffer reported a series of five patients from 1990 to 2004 who underwent similar extra-anatomic bypasses from the ascending aorta to the celiac artery or SMA for CMI. They reported excellent results with no mortalities, and four of the five bypasses were patent at 120 months. The nonpatent bypass was a bifurcated graft in which the SMA segment occluded but the celiac segment remained patent, and the patient remained symptom free.6Chiche L. Kieffer E. Use of the ascending aorta as bypass inflow for treatment of chronic intestinal ischemia.J Vasc Surg. 2005; 41: 457-461Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar The case presented here differs from this series in that the patient described required aortic resection for infected aneurysm and infected endograft, whereas those described by Chiche and Kieffer had unusable distal thoracic and abdominal aorta due to Takayasu disease, Erdheim-Chester disease, and thoracic aortic dissection. Furthermore, our patient underwent placement of a rifampin-soaked Gelsoft graft as has been previously suggested for aortic reconstruction in the face of infection.10Lew W. Moore W. Antibiotic-impregnated grafts for aortic reconstruction.Semin Vasc Surg. 2011; 24: 211-219Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar Given our patient's known MSSA bacteremia and antibiotic sensitivities, rifampin as an adjunctive agent was appropriate for the patient's bacteria. In contrast, four of the bypasses described by Chiche and Kieffer were with greater saphenous vein and the remaining bypass was Dacron. Although an autogenous conduit in a recently infected patient would have been optimal, we elected to use a prosthetic conduit because of lack of suitable vein in the patient. It is important to note that the patient remained on suppressive antibiotics indefinitely. Last, whereas these five patients had the graft tunneled through the central tendon of the diaphragm, we tunneled through a separate incision in the diaphragm as previously noted to allow the graft to sit in a configuration without kinking. In either case, the graft should be placed in a gentle C-shaped curve and should be tunneled retropancreatic to avoid kinking, as can happen with retrograde bypasses from the iliac arteries tunneled through the mesentery. Extra-anatomic bypass from the ascending aorta to the hepatic artery and SMA for revascularization of CMI can be successfully performed with rifampin-soaked prosthetic conduit in the rare setting of a patient with resected infected aorta and no other amenable retrograde or antegrade takeoffs." @default.
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• W2381300960 date "2017-01-01" @default.
• W2381300960 modified "2023-10-14" @default.
• W2381300960 title "Explantation of infected aortic aneurysm and endograft with ascending aorta to mesenteric bypass for mesenteric ischemia" @default.
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