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Background Prosthetic vascular graft procedures are a common treatment modality for peripheral vascular disease. A relatively common complication is graft infection, occurring at a rate of 0.5–5%. When they occur, graft infections are associated with significant morbidity and mortality. Vascular graft infections also represent a diagnostic and therapeutic challenge for the physician Methods Here, we report a case where the rare finding of secondary hypertrophic osteoarthropathy was an important indication of underlying aortic graft infection that was initially misdiagnosed. A review of the literature revealed 34 cases of vascular graft infection associated with hypertrophic osteoarthropathy. Results The mean interval from surgery to time of infection was approximately 5 years. Mortality was 35%. When combined with hypertrophic osteoarthropathy, vascular graft infection was complicated by an aortoenteric fistula in 53% of the cases. Conclusion The complexity of this case highlights the challenges physicians face in order to diagnose and treat this condition.

We report a case of occult Mycobacterium bovis left axillary-bifemoral bypass graft infection, with superimposed acute methicillin-susceptible Staphylococcus aureus (MSSA) infection in an 82 year old male following intravesicular bacillus Calmette–Guerin (BCG) for adjuvant therapy of urothelial cancer. The patient underwent partial removal of the bypass graft and treated with antimycobacterial therapy—rifampin and isoniazid for 9 months, and intravenous cefazolin followed by oral cephalexin for chronic suppressive therapy for MSSA. This presentation highlights the need to consider indolent infection masquerading as mechanical erosion, even when an alternate infection is present.

Objective To compare the in vitro efficacy of graft impregnation with nebacetin versus rifampin versus daptomycin against vascular graft infections caused by Staphylococcus epidermidis and Staphylococcus aureus and nebacetin versus rifampin against Pseudomonas aeruginosa and Escherichia coli . Materials Twenty-three Dacron-grafts (1 cm 2 ) for each micro-organism were microbiologically tested and eight grafts per antibiotic underwent viability tests against human umbilical vein endothelial cells (ECs). Fifteen grafts (5/antibiotic agent) underwent 15 min impregnation and contamination with 4 ml bacterial solution (optical density (OD 600 nm ): 0.20 ± 0.02). After 24-h-incubation, all grafts were washed with phosphate-buffered saline and underwent sonification to release viable adherent bacteria. OD 600 nm of the solution was measured. Afterwards, six 1:10 dilution steps took place and colony-forming units (CFUs) were counted. Results Nebacetin showed comparable efficacy to daptomycin against Gram-positive bacteria. Both eradicated more efficiently S. epidermidis than rifampin (daptomycin:0, rifampin:5 ± 7.3, nebacetin:0 CFU ml −1 , P = 0.0003). All antibiotics showed comparable antibacterial activity against S. aureus. Nebacetin was more efficient than rifampin to eradicate Gram-negative organisms ( P. aeruginosa : rifampin:1308 ± 252, nebacetin:8 ± 8 CFU ml −1 , P = 0.01, E. coli : rifampin:294 ± 159, nebacetin:0.2 ± 0.5 CFU ml −1 , P = 0.001), while only rifampin was toxic against ECs (daptomycin:30.88 ± 5.44, rifampin:5.13 ± 5.08, nebacetin:28.50 ± 3.82 ECs/field, P = 0.0003). Conclusions Nebacetin showed excellent in vitro antibacterial activity against both Gram-positive and -negative pathogens representing an effective candidate for vascular graft impregnation.

Prosthetic vascular grafting is a commonly performed procedure that is central to the management of arterial disease and renal failure. Though rare, vascular graft infections (VGI) are potentially devastating, and carry a high rate of mortality and amputation. Despite extensive research and clinical experience, VGI remain a daunting therapeutic challenge for surgeons and infectious disease specialists. This article reviews the pathogenesis of VGI, in particular the role of biofilms, as well as the current state of clinical management including diagnostic modalities, surgical options for treatment, antimicrobial therapy, and preventive measures.

Prosthetic vascular graft infection is a rare but very severe complication with a high death rate. Its optimal management requires appropriate surgical procedures combined with adequate antimicrobial treatment in reference center. The authors wanted to focus on the management of prosthetic vascular graft infection and define the clinical, microbiological, biological, and radiological criteria of vascular graft infection. Complementary investigations, although these are small series, include CT scan, the gold standard for the diagnosis of acute infection with a sensitivity and specificity reaching 100%, but decreased to 55% in case of chronic infection. More recently, PET-scanning was studied and yielded good results in chronic infections (sensitivity 98%, specificity 75.6%, positive predictive value 88.5%, and negative predictive value 84.4%). Managing prosthetic vascular graft infection, as with the orthopedic and vascular infections, requires replacing the vascular prosthesis. There is no correlation between the microbiological data and the location or type of vascular infection. Thus, the postoperative intravenous antibiotherapy should be bactericidal with a broad-spectrum. After obtaining intra-operative microbiological results, de-escalation therapy must include at least one anti-adherence agent, such as rifampicin in staphylococcal infections.

The purpose of these recommendations is to provide a standard format for reporting treatment results and standardised epidemiologic data after aortic vascular graft infection to improve the comparison of clinical outcomes between different therapeutic approaches and different study populations. Analytical reporting standards for patients’ characteristics, type and extent of the disease, type of treatment and study design are described. Adherence to these recommendations will improve clinical relevance, quality and comparability of future studies dealing with aortic vascular graft infections.

Objectives Biophotonic imaging was compared to standard enumeration method both for counting Staphylococcus aureus in biofilm and bacterial susceptibility tests of different graft materials. Design Prospective, randomized, controlled animal study. Material and methods Five types of vascular grafts were placed subcutaneously in 35 mice and challenged with bioluminescent S . aureus . The mice were divided into equal groups as follows: group A (polyester), group B (polytetrafluoroethylene), group C and D (two types of silver acetate-coated polyester) and group E (bovine pericardium). Controls were given only the bacteria. The bioluminescence signal of S. aureus , able to predict number of viable bacteria in biofilm without any manipulation, was measured at different time points. Five days postinfection, regular cultures of adherent bacteria on grafts were obtained. Comparative analyses between bioluminescence activity and culture enumeration were performed. Results The number of viable bacteria on silver-coated prostheses was the slightest, indicating superior bacterial resistance. The density of bacteria on polytetrafluoroethylene and polyester was comparable, with a non-significant advantage for polytetrafluoroethylene. Moreover, bioluminescence detected the number of viable S. aureus in biofilm more exactly compared to enumeration of bacteria. Conclusion Bioluminescence imaging can be considered a useful tool to characterize susceptibility of any graft material to bacterial biofilm prior to implantation.

Background The aim of the present study was to describe the characteristics and prognosis of patients admitted for a PVGI and to assess the factors associated with the death of these patients. Methods All consecutive patients admitted in our department between January 1, 2000 and January 1, 2018 for a PVGI were enrolled in the present prospective cohort study. PVGIs were divided into extracavitary (femoro-femoral, femoro-popliteal and axillo-femoral) and cavitary (aorto-iliac, aorto-femoral, ilio-femoral, aortic); into “early” infection (

Objectives To evaluate the efficacy of a silver-coated vascular polyester graft in the prevention of graft infection after inoculation with Staphylococcus aureus in a porcine model. Material and methods Eighty-four pigs were randomly selected 1:1 to receive a silver-coated or non-silver-coated 8-mm-wide polyester graft implanted end-to-end in the infrarenal aorta. At the end of implantation, 106 colony forming units (CFUs) S. aureus in 0.3 ml suspension were inoculated directly on the graft surface. Blood samples assayed for white blood corpuscles (WBCs) and C-reactive protein (CRP) were taken before implantation and on the postoperative days 2, 5, 7, 11 and 14. Two weeks after implantation, the perigraft swabs were analysed for S. aureus or contaminants. CFUs of S. aureus were quantified and logarithmised. Student's t-tests, repeated measurement analysis of variance (ANOVA) and chi-square test were employed to compare the two grafts. Results All pigs developed graft infection. There were no statistically significant differences between the silver-coated and non-silver-coated grafts in the quantity of S. aureus, macroscopic signs of infection and postoperative changes in the temperature, WBC and CRP. Conclusions Silver–coated polyester grafts failed to prevent graft infections after inoculation with 106S. aureus in 0.3 ml suspension in a porcine model.

INTRODUCTION Although the incidence is low, infection of prosthetic vascular graft bears a high incidence of serious complications including 25-75% mortality rate and 40-75% limb loss. The standard treatment of vascular graft infection consists of excision of the prosthesis, wound debridement and extraanatomic revascularization. Conservative treatment might be an option in a limited number of patients. We present three cases of surgical and conservative treatment of vascular graft infection. CASE OUTLINE Case 1: A patient developed silver-coated graft infection after femorodistal arterial reconstruction performed because of critical limb ischemia. In the early postoperative period, massive skin and subcutaneous tissue necrosis developed, with the graft being exposed. After two months of persistent debridement and wound toilette, the defect was covered with a Thiersch skin graft. Case 2: PTFE graft infection in the right groin followed reconstruction of the isolated common femoral artery aneurysm. This graft was replaced with a silver-coated graft in situ. Reinfection of the proximal end of the implanted silver-coated graft occurred and the graft was exposed. After repeated debridement and wound toilette, the exposed prosthesis was covered with granulomatous tissue, and the wound healed. Case 3: A year after anastomotic pseudoaneurysm resection in the left groin, prosthesis was exposed following wound infection. This graft was substituted with a silver-coated graft in situ. The wound healed primarily. CONCLUSION These three cases demonstrate that under some circumstances vascular prosthesis infection can be successfully treated conservatively without graft removal, and also by in situ replacement using silver-coated graft.

Here, we present the case of an extremely subtle peripheral graft infection caused by Staphylococcus aureus. The lack of local signs and the negativity of all imaging studies, including (99m)Tc-HMPAO-Labelled-Leukocyte Scan which is reported to have 100% sensitivity, delayed the diagnosis and therapy, which were both provided by surgery.

Objectives Prophylactic efficiencies of cefazolin, teicoplanin and vancomycin in a dacron graft infection model caused by methicillin-susceptible (MSSA) or -resistant Staphylococcus aureus (MRSA) were investigated. Design Prospective, randomized, controlled animal study. Materials and methods Infections were established subcutaneously in the back of rats by implantation of Dacron prostheses followed by topical inoculation onto grafts of MSSA or MRSA. Experimental groups were as follows: Uncontaminated group (control), MSSA- or MRSA-contaminated and untreated groups, MSSA- or MRSA-contaminated groups treated with cefazolin, teicoplanin or vancomycin by one of three regimens (one day, two days, or three days regimen). Grafts were removed 7 days after the implantation and evaluated by using sonication and quantitative blood agar culture. Results Contaminated groups demonstrated graft infections. Cefazolin, teicoplanin and vancomycin profoundly prevented the graft infections in MSSA- or MRSA-contaminated groups. For each antibiotic regimen, the most effective prevention was achieved by the drugs given as three days regimen. For MSSA and MRSA, the order of the effectiveness was as follows: teicoplanin > vancomycin > cefazolin. Conclusion As a prophylactic agent, teicoplanin seems to be more effective than vancomycin and cefazolin against vascular graft infections caused by MSSA and MRSA in rats.

The objectives of this retrospective investigation were to determine the accuracy of 99mTc-fanolesomab, an antigranulocyte antibody, for diagnosing prosthetic vascular graft infection, ascertain optimum imaging times for this indication, and assess safety of this agent.Eighteen patients with 19 prosthetic vascular grafts were included. Indications for graft placement included peripheral vascular disease (8), haemodialysis (7), and aneurysm (4). Patients were imaged 2-5 h and 18-30 h after injection of 555-740 MBq (75-125 microg) 99mTc-fanolesomab. One experienced nuclear physician reviewed images in three separate sessions, early alone, late alone and early plus late images together. When early and late images were read alone, graft activity more intense than native blood pool activity was classified as positive for infection. When early and late images were interpreted together, graft activity which persisted or which increased in intensity over time was classified as positive for infection. Patient records were reviewed for adverse events up to 30 days after injection.Five (26%) prosthetic grafts were infected. Early, late and early plus late imaging were equally sensitive (1.00). Early images were significantly less specific (0.50), than late and early plus late images (0.93) (P0.05, analysis of proportions). Accuracy of late imaging and early plus late imaging were the same: 0.93. No patient experienced adverse events following radiopharmaceutical injection.99mTc-fanolesomab imaging, performed 18-30 h after injection, diagnosed prosthetic vascular graft infection safely and accurately (95%). (Although safety was not an issue in this investigation, following reports of serious, including two fatal, events after administration, 99mTc-fanolesomab was withdrawn from the United States market).

Background Vascular graft infections are infrequent complications with important morbidity and mortality rates. Pasteurella multocida, a Gram negative bacillus, is a normal oral commensal of many animals. For mankind, it is a pathogenous bacillus which is rarely implicated in vascular grafts. Case report We report hereafter the fourth case introduced in the international literature about vascular graft infections caused by P. multocida. The patient was successfully treated with a combination of a surgical graft change and a 6 weeks bi-antibiotic therapy. Discussion There is fours case reported in litterature with quite different antibiotic drugs and duration. Conclusion P. multicoda graft infection should be long with initial intravenous drug and mainteance traitement should not be required.

Introduction: We present a rare case of wound and vascular graft infection caused by Haemophilus parainfluenzae after reconstruction of the femoral artery bifurcation. Case presentation: H. parainfluenzae was isolated from pus samples taken from a patient who had undergone angioplasty of the superficial femoral artery and anastomosis with a synthetic graft. The pathogen was isolated from samples taken from both the wound and the graft. Management involved wide surgical debridement and irrigation, preservation of the prosthetic graft and transposition of muscle flaps in conjunction with the administration of culture-based antimicrobials. Conclusion: H. parainfluenzae surgical wound and vascular graft infections are uncommon, and quick diagnosis and preservation of the graft is of great importance in treatment.

• In the general ward setting, we observe high rates of both gram positive and gram negative organisms causing vascular graft infections (VGI).

Prosthetic vascular graft infection (PVGI) is a rare but significant complication of arterial reconstructive surgery. Although the relative risk is low, the clinical consequences can be catastrophic. Microbiological data on causative bacteria are limited. We present four cases of late-onset PVGI. Using a culture-independent nucleic acid amplification method for analysis of intraoperative samples, the presence of bacteria highly suggestive of an oral source was reported. Examination by an oral health specialist confirmed the presence of chronic periodontal disease. We hypothesize that chronic oral infection may be a previously unreported risk factor for the development of late-onset PVGI.

Diagnosis of prosthetic vascular graft infection (PVGI) is a clinical challenge requiring accurate diagnostic methods for their optimal management. A 65-year-old patient with suspected PVGI was explored by fluorodeoxyglucose positron emission tomography combined with computed tomography ((18)F-FDG PET-CT) for pretreatment staging. Standard imaging was unrevealing but PET images showed multiple foci with increased uptake suggesting prosthetic infection. While routine results from the diagnostic laboratory were negative, prosthesis sonication before standard culture revealed the same bacterium as a culture of preoperative lymphocele aspiration. (18)F-FDG PET-CT and preliminary sonication of the prosthetic graft could be very helpful in the diagnosis of PVGI especially for highlighting biofilm bacteria.

Background In vascular surgery, surgical site infection is the most common postoperative morbidity, occurring in 5–10% of vascular patients. The optimal management of surgical site infection with involved lower limb vascular grafts remains controversial. We present our 6-year results of using the V.A.C.® system in surgical site infection with involved vascular grafts. Methods A retrospective 6-year review of patient who underwent a VAC® therapy for postoperative surgical site infection in lower limb with involved vascular grafts in our department between January 2006 and December 2011. V.A.C therapy was used in 40 patients. All patients underwent surgical wound revision with VAC® therapy and antibiotics. Results The mean time of use of the V.A.C. system was 14.2 days. After mean of 12 days in 34 of 40 patients, in whom the use of VAC® therapy resulted in delayed primary closure or healing by secondary intention. The mean postoperative follow-up time was 61.67 months, during which 3 patients died. Conclusion We showed that the V.A.C.® system is valuable for managing specifically surgical site infection with involved vascular grafts. Using the V.A.C.® system, reoperation rates are reduced; 85% of patients avoided graft replacement.

Objectives The purpose of this experimental study was to compare the susceptibility of gelatin-sealed Dacron and PTFE prostheses to infection by MRSA. Design Prospective, randomized, controlled animal study. Materials and Methods Graft infections were established in the subcutaneous tissues of 60 female Spraque-Dawley rats by the implantation of gelatin-sealed Dacron or PTFE prostheses followed by topical inoculation with methicillin-resistant Staphylococcus aureus . The study groups were as follows: (1A) uncontaminated gelatin-sealed Dacron group, (1B) untreated contaminated gelatin-sealed Dacron group, (1C) contaminated gelatin-sealed Dacron group with intraperitoneal teicoplanin treatment, (2A) uncontaminated PTFE group, (2B) untreated contaminated PTFE group, and (2C) contaminated PTFE group with intraperitoneal teicoplanin treatment. The grafts were removed after 7 days and evaluated for infection by counting the number of adherent bacteria on the graft material after rinsing and sonication. The perigraft tissue was harvested for histopathological study. To investigate the existence of any infection, blood samples were collected by cardiopuncture for a culture analysis. Results No significant difference in bacteria counts was observed between gelatin-sealed Dacron and PTFE grafts. In groups 1A and 2A, there was no infection detected. The bacterial counts for MRSA were 7.4×10 5 in group 1B and 8.6×10 5 in group 2B. There was also no infection in groups 1C and 2C. While the difference between group 1B and 2B was not significant ( p >.05), bacterial counts in group 1B or 2B were significantly higher than those in other groups. Blood cultures were only positive in four rats in group 1B and in two rats in group 2B. The severities of the inflammation of the perigraft tissues was low in groups 1A and 2A, high in groups 1C and 2C, and between the range from low to moderate in groups 1B and 2B. Conclusion The susceptibility of gelatin-sealed Dacron to bacterial infection was not higher than that of PTFE.

Objectives To compare the efficacy of a single prophylactic dose of intra-peritoneal vancomycin and teicoplanin with anti-biotic treated Dacron grafts (vancomycin, teicoplanin, 10 or 40% fusidic acid-soaked grafts) in preventing vascular graft infections in a rat model. Design Prospective, randomized, controlled animal study. Materials and methods The graft infections were established in the subcutaneous tissues of 80 female Sprague–Dawley rats by the implantation of Dacron prostheses followed by the topical inoculation with methicillin-resistant Staphylococcus aureus. The study groups were as follows: (1) uncontaminated control group, (2) untreated contaminated group, (3) contaminated group with intra-peritoneal vancomycin, (4) contaminated group with intra-peritoneal teicoplanin, (5) contaminated group received vancomycin-soaked Dacron graft, (6) contaminated group received teicoplanin-soaked Dacron graft, (7) contaminated group received 40% fusidic acid-soaked Dacron graft, and (8) contaminated group received 10% fusidic acid-soaked Dacron graft prophylaxis. The grafts were removed after 7 days and evaluated by a quantitative culture analysis. Results No infection was detected in controls. The untreated contaminated group had a high bacteria count (6.0×10 4 CFU/cm 2 Dacron graft). Groups that received intra-peritoneal vancomycin or teicoplanin had less bacterial growth (4.8×10 3 and 3.9×10 3 CFU/cm 2 Dacron graft, respectively). Similarly, the group that received 10% fusidic acid-soaked graft showed less bacterial growth (3.6×10 3 CFU/cm 2 Dacron graft). The groups with vancomycin-, teicoplanin- and 40% fusidic acid-soaked grafts showed no evidence of infection. Statistical analyses demonstrated that intra-peritoneal prophylactic antibiotic treatment was less effective in inhibiting bacterial growth than high concentration antimicrobial-soaking of grafts. Conclusion The use of vancomycin-, teicoplanin- and 40% fusidic acid-soaked grafts was effective in preventing primary prosthetic vascular graft infection.

Prosthetic vascular graft infection is an uncommon yet serious condition. Traditional management has included debridement, excision of the infected graft, and revascularization as needed. We report on two cases in which limb viability was maintained by using endovascular native vessel recanalization after excision of infected prosthetic grafts. This approach was successful in maintaining adequate limb perfusion in both cases. Endovascular native vessel recanalization should be considered as an option to maintain limb viability after excision of infected prosthetic vascular grafts, especially when autogenous conduit is lacking or limitation of the extent of surgery is desirable.

Objectives. To evaluate the efficacy of silver- or Triclosan-coated prosthetic material compared to Rifampin bonded Dacron concerning their resistance to infection following subcutaneous implantation and contamination with Staphylococcus aureus . Design. Animal experimental study in mice. Material and methods. Thirty-six C3H/HcN mice (Charles River Lab., Sulzfeld, Germany) with a weight between 24 and 27 g were randomised into six groups counting six animals each. Group I: control, gel-sealed dacron graft, group II: gel-sealed dacron graft and local contamination, group III: Intergard ® -Silver-prosthesis and contamination, group IV: silver/gel-sealed dacron prosthesis (test graft) and contamination, group V: Rifampin-bonded gel-sealed graft and contamination, group VI: Triclosan/collagen-coated dacron graft and contamination. Dacron graft material 0.8×1 cm was subcutaneously implanted in mice. Local contamination with 2×10 7 /0.2 ml S. aureus ATCC 25923 was carried out in groups II to VI. On day 14 the animals were killed and the grafts were explanted. The microscopic, histologic and microbiological evaluation of the graft material and the perigraft tissue was performed. Results. In control group I no case of infection was detected. In group II, 6 of 6 animals showed infection. In group III (Intergard ® -Silver) and group IV (silver/gel-test graft) were 6 of 6, in group V (Rifampin) only 1 of 6 grafts and in group VI (Triclosan) 4 of 6 grafts were infected. The difference between the low rate of infection in group V (Rifampin) in comparison to the completely infected groups III and IV (Silver) as well as the control group II was significant. Treatment of grafts with Triclosan could prevent infection only in 1/3 of the cases in group IV. Conclusion. Silver coating failed to prevent graft infection material. A potential antimicrobial property was evident for Triclosan whereas Rifampin-bonded grafts exhibit a significantly reduced infection rate. Thus, silver-coated vascular grafts cannot ensure protection from vascular graft infection.

Corynebacterium spp. have proven their pathogenic potential in causing infections, particularly in the setting of immunosuppression and prosthetic devices. We conducted a PubMed literature review of all cases of Corynebacterium prosthetic device infections published in the English language through December 2013. The majority of cases involved peritoneal dialysis and central venous catheters, but prosthetic joints and central nervous system shunts/drains were also involved. The management of these cases in terms of retention or removal of the device was not uniform; however, the overall mortality remained the same among both groups. All of these prosthetic device infections pose potential problems in management when the device cannot be removed safely for the patient, especially with the lack of data on the pathogenicity of Corynebacterium species. However with better identification of species and sensitivities, successful treatment is possible even with retention of the device.

In situ prosthetic graft replacement (ISPGR) of an infected prosthesis raises the risk of recurrent infection in the new graft, especially in cases involving drug-resistant microorganisms. The purpose of this animal study was to evaluate in situ replacement of a vascular graft infected by a highly rifampin-resistant strain of Staphylococcus epidermidis with the use of a rifampin-bonded polyester graft. Antibiotic bonding was obtained by soaking grafts in a high dose of rifampin solution (60 mg/mL). The infrarenal abdominal aorta of 20 dogs was replaced using a polyester prosthesis infected with a highly rifampin-resistant strain of Staphylococcus epidermidis. One week later, the 18 surviving animals were randomized into three groups. Group I (n = 6) did not undergo reoperation. Group II (n = 6) underwent ISPGR using a rifampin-bonded prosthesis. Group III (n = 6) underwent ISPGR using an untreated prosthesis. All surviving animals were killed 28 days after the first procedure. Infectious signs were noted and bacteriological study was carried out on explanted prostheses and various tissue samples. The findings of this experimental study show that soaking a polyester prosthesis in a high-dose rifampin solution can prevent reinfection after in situ replacement of a prosthesis infected by a highly rifampin-resistant Staphylococcus epidermidis.

われわれの経験した胸部大動脈瘤手術224例のうち, 胸骨ないし縦隔から排膿した13例に, 創部に感染所見なく術後血中から細菌が検出された1例を含めて14例を人工血管感染例として取り上げ検討した. 10例で胸骨ないし縦隔から, 6例で血中から, 細菌が検出された. 14例中13例に対し病変の深達度が浅ければ感染部位の除去を, 深ければ, それに持続洗浄を, また最近では, さらに大網充填を組み合わせる方針で再手術を施行した. 4例が在院死亡となった. 死亡例はすべて血中から細菌が検出されていた. 結局感染が制御され, 退院できたのは10例であった. 本深在性創部感染は, すでに人工血管に感染しているか, その危険性が高度と考えられ, われわれは早急に再手術を施行してきたが, 3例が死亡したことは本合併症の重篤なことを示している. またとくに血中に細菌が認められると非常に危険といえよう.

It has been estimated that as many as 10,000 patients each year present with vascular graft infection in the United States. Although prosthetic graft infection remains a demanding challenge for the surgeon and a potentially devastating complication for the patient, in recent years management options have increased, and the surgical outcome has improved. Although septic involvement of the main body of an aortoiliac/femoral, or the entire extent of an infrainguinal, bypass continues to require complete graft excision in most cases, among patients with more localized infection there is growing evidence that aggressive local wound care may allow salvage of all or most of the origi nal conduit. Graft coverage with well-vascularized skeletal muscle represents an innovative refinement of the local management of prosthetic graft infection, which may not only increase the likelihood of successful graft salvage but also allow this local management strategy to be extended to cases that formerly would have required g...

Purpose : The purposes of this study were to prove the efficacy of cryopreserved aortic allografts to treat an established vascular graft infection by in situ replacement in an animal model and to evaluate the role of the antibiotics normally used to decontaminate the allografts. Methods : Twenty-three dogs underwent infrarenal aortic replacement with a gelatin-sealed knitted polyester graft contaminated in vitro by staphylococcus epidermidis RP-62. One week later, the 18 surviving animals underwent reoperation for graft removal and were randomized into three groups for in situ replacement: group I (control, n = 6) received a new gelatin-sealed graft; group II ( n = 6) received a non–antibiotic-treated cryopreserved allograft; and group III ( n = 6) received an antibiotic-treated cryopreserved allograft. Control grafts and allografts were removed 4 weeks after the initial intervention for quantitative bacteriologic analysis and histologic analysis. Bacteriologic results were expressed as colony-forming units per square centimeter of graft material. Qualitative bacteriologic analysis was also obtained from perigraft fluid and tissue. Results : All of the initially implanted grafts and all of the control grafts (group I) were infected at the time of removal. In group II, three out of six allografts were not totally incorporated, whereas in group III incorporation was always complete, with a significantly decreased inflammatory reaction. All of the antibiotic-treated allografts were sterile, whereas three untreated allografts grew bacteria. Conclusions : In this model, cryopreserved aortic allografts were more resistant to reinfection than synthetic grafts after in situ replacement of an infected prosthetic graft. However, the antibiotic loading of the cryopreserved aortic allograft appears to be essential to obtain optimal therapeutic effects. (J Vasc Surg 1998;27:689-98.)

Because the morbidity and mortality after treatment of an established vascular infection is prohibitively high, prevention of local infection should be the primary aim, especially if a prosthetic graft has to be used. Once the infection has occurred, the infected graft must usually be removed. Extra-anatomic bypass or autograft replacement with arterial or venous conduits are frequently used for revascularisation of non-viable organs or extremities. Recently in situ implantation of allografts or prosthetic grafts has been considered as a possible alternative in high risk patients or in patients with poor run-off if complex secondary revascularisation was not feasible. I-5 Many methods have been described to create an infection-resistant graft, binding various antibacterial substances to the vascular prostheses. 6-11 This paper documents our clinical experience with the rifampicin-bonded graft. Eight patients were operated on as an emergency. Seven patients had total graft replacement and four partial replacement of the graft for infection limited to the groin (Fig. 1). The treatment consisted of parenteral antibiotic treatment with oxacillin, accurate skin preparation, graft removal, generous wound debridement and local antiseptic treatment with betadine. After gloves and instruments had been changed a new gelatine-coated Dacron prosthesis was soaked with 600 mg rifampicin diluted with 10 ml NaC1 0.9% for 10-15 min before implantation. If residual contamination could not be excluded, continuous irrigation of the wound with betadine for 48-72 h was performed. All patients received postoperative intravenous antibiotics on the basis of the sensitivities. Bacteriological studies of the removed prosthesis showed Staphylococcus aureus in eight cases and Staphylococcus epidermidis in four.

Although the incidence of prosthetic infection is low (1%-6%), the consequences (limb loss or death) are dramatic for a patient, with high mortality rate (25%-75%) and limb loss in 40%-75% of cases. In case of Szilagyi's grade III infection, standard procedure consists of the excision of prosthesis and wound debridement. Alternative method is medical treatment. This is a case report of a patient with prosthetic infection of Silver-ring graft, used for femoropopliteal reconstruction, in whom an extreme skin necrosis developed in early postoperative period. This complication was successfully treated medically. After repeated debridement and wound-packing, the wound was covered using Thiersch skin graft.

We report a case of late-onset aortic prosthetic vascular graft infection. We stress the importance of maintaining a high index of suspicion for any patient presenting with fever on the background of in situ prosthetic material. We present the difficulties in managing these extremely complicated, often life and limb threatening infections and suggest that a multidisciplinary team approach, involving specialist centre referral, may be key to success. We highlight the difficulties in diagnosing late-onset PVGI, where presentation can be subacute with subtle signs and confusing microbiology. In this case the presentation was pyrexia of unknown origin with multiple positive blood cultures isolating a variety of gut-associated organisms;a wolf in sheep’s clothing.

Background There exists considerable debate concerning management of prosthetic vascular graft infection (PVGI), especially in terms of antimicrobial treatment. This report studies factors associated with treatment failure in a cohort of patients with staphylococcal PVGI, along with the impact of rifampin (RIF). Methods All data on patients with PVGI between 2006 and 2010 were reviewed. Cure was defined as the absence of evidence of infection during the entire post-treatment follow-up for a minimum of one year. Failure was defined as any other outcome. Results 84 patients (72 M/12 F, median age 64.5 ± 11 y) with diabetes mellitus (n = 25), obesity (n = 48), coronary artery disease (n = 48), renal failure (n = 24) or COPD (n = 22) were treated for PVGI (median follow-up was 470 ± 469 d). PVGI was primarily intracavitary (n = 47). Staphylococcus aureus (n = 65; including 17 methicillin-resistant S. aureus) and coagulase-negative Staphylocococcus (n = 22) were identified. Surgical treatment was performed in 71 patients. In univariate analysis, significant risk factors associated with failure were renal failure (p = 0.04), aortic aneurysm (p = 0.03), fever (p = 0.009), aneurysm disruption (p = 0.02), septic shock in the peri-operative period (p = 0.005) and antibiotic treatment containing RIF (p = 0.03). In multivariate analysis, 2 variables were independently associated with failure:septic shock [OR 4.98: CI 95% 1.45-16.99; p=0.01] and antibiotic containing rifampin [OR: 0.32: CI95% 0.10-0.96; p=0.04]. Conclusion Results of the present study suggest that fever, septic shock and non-use of antibiotic treatment containing RIF are associated with poor outcome.