P-039 - SURGEON-MADE PORCINE PERICARDIAL AORTIC TUBES IN TREATMENT OF NATIVE, AS WELL AORTIC GRAFT INFECTIONS - MID-TERM RESULTS

TOPIC:
Vascular Infection
AUTHORS:
Znaniecki L. (Medical University of Gdańsk, Department of Cardiac and Vascular Surgery ~ Gdańsk ~ Poland) , Brzezinski J. (Medical University of Gdańsk, Department of Cardiac and Vascular Surgery ~ Gdańsk ~ Poland) , Halman J. (Medical University of Gdańsk, Department of Cardiac and Vascular Surgery ~ Gdańsk ~ Poland) , Wojciechowski J. (Medical University of Gdańsk, Department of Cardiac and Vascular Surgery ~ Gdańsk ~ Poland)
Introduction:
The material used for treatment of primary aortic infections as well as aortic graft infections is still a matter of discussion. The use of bovine pericardium is allowed as an alternative solution by recent ESVS Guidelines on Vascular Graft Infections (IIa, C), but long-term observations on larger populations are neccessary. Porcine pericardium has been proven to have comparable mechanical properties.1,2 It is widely used in TAVI valves and there have been reports of success in peripheral arterial infection repair.3,4 This study presents early as well as mid-term results and durability of use of surgeon-made porcine pericardium tubes used as in-situ reconstruction of aortic infections. To our knowledge, this is the first report of porcine pericardium use in treatment of aortic infections.
Methods:
This is a retrospective analysis performed at a single institution (regional Vascular Surgery referral center). We analyzed outcomes of eight patients treated for infectious aortic disease between June 2016 and March 2022 with surgeon-made pericardial tubes constructed of porcine pericardial patch. Clinical, infectious, and follow-up data were evaluated and imaging was reviewed to assess durability.
Results:
Treatment group consisted of 7 males and one female with a median age of 68,5 years. Seven patients had an infection of abdominal aorta segment and one patient had infection in the iliac artery. Three patients had primary aortic infection and five patients had aortic graft infections (4 after OAR and 1 after EVAR). Four of aortic graft infection patients had aorto-enteric fistula (AEF). We used MAGIC criteria to confirm aortic infection in all cases, primary as well as secondary.5 Gram-positive organisms were cultured in 6 patients, Gram-negative organisms were cultured in 3 cases and fungal infection was confirmed in 4 patients. Biointegral No-React porcine pericardial patch 8x14 cm (BioIntegral Surgical Inc., Mississauga, ON, Canada) was used to create a neo-aortic tube that was implanted in-situ in all patients. Technical success defined as resection of all infected material and successful neo-aortic tube implantation with excellent hemostasis was 100%. In hospital mortality occurred in one patient treated in an emergency setting after massive bleeding from AEF. Death occurred 21 days after the procedure, due to severe septicemia and Multi Organ Failure. Median follow-up was 12 months (2-63 months). Follow-up imaging was performed in 6 patients in a median time of 30 months after the index procedure (5-44 months). Persistent infection was diagnosed in 2 patients treated for aortic graft infections. In those two patients, AEF was not diagnosed and hence not repaired during the index procedure. Cultures taken during re-operations revealed multi-resistant organisms - VRE and KPC. Both of those patients died in mid-term observation. One patient had suture-line aneurysm in 18 months of follow-up imaging, with no gas / fluid collection and normal laboratory exams, so no reinfection was diagnosed. Follow-up imaging of remaining patients (performed 63, 43 and 3 months after index procedure) revealed no graft-related complications such as aneurysm formation, calcification, thrombosis, stenosis.
Conclusion:
Surgeon-made tubes constructed with porcine pericardial patch may be safely used in primary as well as graft-related abdominal aortic infections and they seem non-inferior to bovine patch tubes. Survival depends not only on aortic repair but also on the scrutiny of searching for bowel fistulation and bowel repair. In patients with successful enteric repair we observed no mid-term graft related complications in bacterial infections. On the contrary, in fungal infections the mid-term success is uncertain.
References:
1. Chakfé N, Diener H, Lejay A, et al. European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Vascular Graft and Stent Graft Infections With the Endorsement of the European Association of Nuclear Medicine (EANM). Eur J Vasc Endovasc. 2020;59(J Vasc Surg 42 2005):339-384. doi:10.1016/j.ejvs.2019.10.016 2. Zouhair S, Sasso ED, Tuladhar SR, et al. A Comprehensive Comparison of Bovine and Porcine Decellularized Pericardia: New Insights for Surgical Applications. Biomol. 2020;10(3):371. doi:10.3390/biom10030371 3. Rahmani B, McGregor C, Byrne G, Burriesci G. A Durable Porcine Pericardial Surgical Bioprosthetic Heart Valve: a Proof of Concept. J Cardiovasc Transl. 2019;12(4):331-337. doi:10.1007/s12265-019-09868-3 4. Metzger P. First Experiences in the Use of No-react® Biointegral Graft and No-react®Biointegral Surgical Patch in PTFE Prosthesis Infection After Arterial Reconstruction. Eur J Vasc Endovasc. 2019;58(6):e740. doi:10.1016/j.ejvs.2019.09.287 5. Lyons OTA, Baguneid M, Barwick TD, et al. Diagnosis of Aortic Graft Infection: A Case Definition by the Management of Aortic Graft Infection Collaboration (MAGIC). Eur J Vasc Endovasc. 2016;52(6):758-763. doi:10.1016/j.ejvs.2016.09.007