P-040 - PARACOLIC GUTTER ROUTING: A NOVEL EXTRA-ANATOMICAL COURSE FOR INFECTED AORTO-ILIAC AXIS

TOPIC:
New vascular techniques and devices
AUTHORS:
El Beyrouti H. (Department of Cardiac, and vascular Surgery, University medical center, Johannes Gutenberg University ~ Mainz ~ Germany) , Halloum N. (Department of Cardiac, and vascular Surgery, University medical center, Johannes Gutenberg University ~ Mainz ~ Germany) , Abualia M. (Department of Cardiac, and vascular Surgery, University medical center, Johannes Gutenberg University ~ Mainz ~ Germany) , Abdalhafez M. (Department of Cardiac, and vascular Surgery, University medical center, Johannes Gutenberg University ~ Mainz ~ Germany) , Doemland M. (Department of Cardiac, and vascular Surgery, University medical center, Johannes Gutenberg University ~ Mainz ~ Germany) , Treede H. (Department of Cardiac, and vascular Surgery, University medical center, Johannes Gutenberg University ~ Mainz ~ Germany) , Omar M. (Department of Cardiac, and vascular Surgery, University medical center, Johannes Gutenberg University ~ Mainz ~ Germany)
Introduction:
Management of infected native or aorto-ilio-femoral grafts can be challenging. Surgical debridement and replacement of infected segments is necessary, but close proximity of grafts to the infected field leads to high re-infection rates. Several graft materials for in situ reconstruction were tested to prevent infection recurrence with variable results, and extra-anatomical bypass techniques (such as axillo-bifemoral bypass) were also proposed, but are associated with increased morbidity and mortality. We describe here a novel extra-anatomical para-colic course that we have been using to manage infections of aorto-iliac axishou5 with improved results.
Methods:
6 of patients (3 males, aged 69 ± 12 years) with infected aorto-iliac axis were operated on using the paracolic gutter technique. 1 (17%) patient had undergone prior endovascular repair, 3 (50%) patients had undergone redo procedures, and 2 (33%) patients had recurrent re-infections. Mycotic aneurysms were present in 2 (33%) patients and aorto-ureteric fistulae in 1 (17%) patient. This procedure is carried out through a median laparotomy. All infected native and synthetic materials are removed, the surrounding tissues are radically debrided. An antibiotic-soaked Y-graft is anastomosed in an end-to-end fashion to the proximal segment of the aorta. Branch grafts on either side are routed retroperitoneally behind the colon and into the paracolic gutter, and extended down to the groin, and are then anastomosed to the femoral vessels. Complete retroperitonealisation of graftmaterial is therefore ensured.
Results:
All Patients received extra-anatomical aortobifemoral grafts using the described technique. Duration of ICU stay was 2.2 ± 1 days and of in-hospital stay 17 ± 6 days. There were no major complications and no in-hospital mortalities. All patients were followed up for 15 ± 12 months, and there were no operation-related late mortalities. Follow up of graft prostheses was carried out using Doppler ultrasonography and/or CT. None of the grafts showed any signs of recurrent infections during the follow-up period of x months/weeks. There was one case of graft thrombosis (17%) with subsequent successful thrombectomy, and early surgical revision was required in 1 patient (17%). All graft prostheses were patent at latest follow-up.
Conclusion:
Creation of a neo-aortofemoral system using a retroperitoneal, retro- and para-colic routing is a safe approach in a heterogeneous cohort of patients, and complements other bail-out procedures where surgery may be associated with a high risk of reinfection. Long-term follow-up is mandatory.