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Objective: The optimal revascularization modality following complete resection of aortic graft infection (AGI) without enteric involvement remains unclear. The purpose of this investigation is to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients undergoing complete excision of AGI. Methods: A retrospective, multi-institutional study of AGI from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and perioperative variables were recorded. The primary outcome was infection-free survival. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariable analyses were performed. Results: A total of 241 patients at 34 institutions from seven countries presented with AGI during the study period (median age, 68 years; 75% male). The initial aortic procedures that resulted in AGI were 172 surgical grafts (71%), 66 endografts (27%), and three unknown (2%). Of the patients, 172 (71%) underwent complete excision of infected aortic graft material followed by in situ (in-line) bypass (ISB), including antibiotic-treated prosthetic graft (35%), autogenous femoral vein (neo-aortoiliac surgery) (24%), and cryopreserved allograft (41%). Sixty-nine patients (29%) underwent extra-anatomic bypass (EAB). Overall median Kaplan-Meier estimated survival was 5.8 years. Perioperative mortality was 16%. When stratified by ISB vs EAB, there was a significant difference in Kaplan-Meier estimated infection-free survival (2910 days; interquartile range, 391-3771 days vs 180 days; interquartile range, 27-3750 days; P < .001). There were otherwise no significant differences in presentation, comorbidities, or perioperative variables. Multivariable Cox regression showed lower infection-free survival among patients with EAB (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.6-3.6; P < .001), polymicrobial infection (HR, 2.2; 95% CI, 1.4-3.5; P = .001), methicillin-resistant Staphylococcus aureus infection (HR, 1.7; 95% CI, 1.1-2.7; P = .02), as well as the protective effect of omental/muscle flap coverage (HR, 0.59; 95% CI, 0.37-0.92; P = .02). Conclusions: After complete resection of AGI, perioperative mortality is 16% and median overall survival is 5.8 years. EAB is associated with nearly a two and one-half-fold higher reinfection/mortality compared with ISB. Omental and/or muscle flap coverage of the repair appear protective. © 2022 Society for Vascular Surgery

Sedimentary petrology and trace element geochemistry indicate that the Late Devonian to Early Carboniferous Heishantou Formation near Boulongour Reservoir (NW Xinjiang, China) was deposited on a steep slope, mid-latitude accreting island arc complex in an open oceanic system. Bulk 87Sr/86Sr ratios show excursion patterns that are consistent with excursions at the Devonian-Carboniferous (D-C) boundary in epicontinental margin sediments. Sedimentation rates for the Boulongour Reservoir sediments show highly variable rates that range from 0.5 cm/ky to 10 cm/ky, consistent with other Late Devonian sections and modern arc environments. Multiple whole rock geochemical proxies for anoxia and the size and distribution of pyrite framboids suggest the presence of the Hangenberg Event in the sediments associated with the D-C boundary, despite the lack of visible black shale. The presence of anoxia in an open ocean, island arc environment cannot be explained by upwelling of anoxic bottom waters at this paleolatitude, but can be explained by the global infliction of oceanic shallow water eutrophication on to a climate system in distress.