A technique for a self made bifurcated graft with bovine pericardial patch in infectious vascular reconstruction

A technique for a self made bifurcated graft with bovine pericardial patch in infectious vascular reconstruction INNOVATIVE TECHNIQUES From th ment bergb Surge Author Corresp Hosp schw The edi disclo[.]

INNOVATIVE TECHNIQUES

A technique for a self-made bifurcated graft with bovine

pericardial patch in infectious vascular reconstruction

Corinne Kohler, MD,aNicolas Attigah, MD,aSerdar Demirel, MD,bAlicja Zientara, MD,cMarkus Weber, MD,d

andIgor Schwegler, MD,aZürich, Switzerland; and Heidelberg, Germany

The choice of a suitable vascular graft in infected anatomic sites can be demanding and is still an area of discussion When urgent repair is needed and no appropriate autologous veins are available, self-made bovine grafts are a viable option We present a possible solution for the technical aspects of an infected vascular reconstruction by a self-made bovine pericardial Y graft for aortic reconstruction in a primary aortoentericfistula (J Vasc Surg Cases 2016;2:158-60.)

Graft infections or infected blood vessels in need of

reconstruction are often limb- and life-threatening

con-ditions and are usually technically challenging Most

recent studies still report an incidence of primary arterial

infections and graft infections ranging from 0.5% to 4%.1,2

Several approaches have been described to address the

problem of prosthetic graft or vascular infections, such as

mycotic aneurysms and aortoenteric fistulas Although

autologous vein graft reconstruction remains the gold

standard in graft infection, extra-anatomic

reconstruc-tion or in situ reconstrucreconstruc-tion with arterial homografts,

silver-impregnated grafts, or biosynthetic grafts with

ovine collagen have been described as alternatives.3

The patient provided informed consent for the technical

description and the related case report outlined below.

CASE REPORT

A 60-year-old man was admitted with an acute aortic

syndrome Inflammatory markers were raised (C-reactive protein

level, 175 mg/dL; white blood cell count, 15 109/L) The patient

reported sentinel upper gastrointestinal bleeding the same day

and discomfort in the left lower abdominal quadrant Computed

tomography (CT) identified a primary aortoduodenal fistula

arising from a large juxtarenal aneurysm (diameter, 7.7 cm)

and secondary spondylodiscitis (lumbar vertebra 2-4;Fig 1)

The patient was hemodynamically stable, but the situation

was judged urgent with the recent sentinel bleeding Because of the juxtarenal configuration of the aneurysm, an

extra-anatomic reconstruction with an axillobifemoral bypass and creation of an aortic stump would have implied the risk of compromising both renal arteries and aortic stump rupture

We therefore decided to do an urgent anatomic reconstruc-tion with a Y graft tailored from a bovine pericardial patch (Fig 2)

After débridement of the infected aortic tissue and vertebra 2,

3, and 4, the proximal anastomosis was sewn with suprarenal clamping of the right renal artery (clamping time, 34 minutes) The distal anastomosis was established at the level of both com-mon iliac arteries Because of the imminent risk of severe bleeding, we decided to manufacture the graft before the lapa-rotomy This also reduced clamping time, because the time for tailoring and sewing took w45 minutes The sizing was esti-mated from the CT scan

Fig 1 Axial computed tomography (CT) scan shows a large juxtarenal aneurysm with the aortoduodenal fistula attached to the anterior aneurysm wall (air bubbles) and spondylodiscitis of the lumbar vertebra 2, 3, and 4 Because of an intact posterior face, segmental stability was judged stable

From the Department of Vascular Surgery, Triemli Hospital, Zürich a ; the

Depart-ment of Vascular and Endovascular Surgery, University of Heidelberg,

Heidel-berg b ; and the Department of Cardiac Surgery c and Department of Visceral

Surgery, d Triemli Hospital, Zürich.

Author con flict of interest: none.

Correspondence: Igor Schwegler, MD, Department of Vascular Surgery, Triemli

Hospital, Birmensdorferstr 497, Zürich 8067, Switzerland (e-mail: igor.

schwegler@triemli.zuerich.ch ).

The editors and reviewers of this article have no relevant financial relationships to

disclose per the Journal policy that requires reviewers to decline review of any

manuscript for which they may have a conflict of interest.

2468-4287

Ó 2016 The Authors Published by Elsevier Inc on behalf of Society for Vascular

Surgery This is an open access article under the CC BY-NC-ND license ( http://

creativecommons.org/licenses/by-nc-nd/4.0/ ).

http://dx.doi.org/10.1016/j.jvscit.2016.08.005

158

The duodenalfistula was exposed by a Kocher maneuver The

fistula itself presented between the second and third portion of

the duodenum Because of the proximity of the pancreatic

head, a wedge resection was performed under visualization of

the ampulla of Vater rather than a segmental duodenal

resec-tion The duodenum was drained with Blake drain, but the

aortic reconstruction was not drained (Fig 3) After thorough

irri-gation of the abdominal cavity, the omentum was mobilized

and partially divided to cover the duodenal anastomosis and

the aortic prothesis

A port catheter was implanted for a 3-month antibiotic

regimen with ertapenem for the treatment of Parvimonas

micra,Hafnia alvii,Streptococcus mitis, anaerobic intestinalflora,

andVeillonellaspp The patient was discharged in overall satis-fying condition after 4 weeks, with a C-reactive protein of

7 mg/dL and a white blood cell count of 4.5 109

/L

A positron emission tomography-CT scan for follow-up

6 months after the operation showed metabolic activity in the débrided lumbar vertebra 4/5 consistent with possible chronic osteomyelitis but no metabolic activity around the bifurcated bovine graft The C-reactive protein level (<5 mg/dL) and white blood cell count (6.3 109/L) were within normal range

DISCUSSION Infectious conditions requiring reconstruction of major vessel because of infected grafts, mycotic aneurysms, or aortoenteric fistulas are associated with high mortality rates Several approaches have been described in the literature, ranging from extra-anatomic reconstruction

or anatomic reconstruction using vein grafts, homografts, silver-impregnated grafts, or biosynthetic grafts with ovine collagen.3-6 So far, there is little evidence about self-made grafts from bovine pericardium However, Czerny et al7reported a case series of 15 patients treated successfully with xenopericardial tube grafts, and tech-nical success and preliminary results were promising in our own small series.8

With the use of bovine pericardial patches, tailoring complex grafts of almost any size is possible Thus, prob-lems with availability and size, such as is the case with homografts, can be avoided Furthermore, the use of homografts in most countries is controlled by the federal law concerning the transplantation of organs, tissue, and cells Reconstruction with vein grafts remains the gold standard, but existence in an appropriate size and qual-ity is not always given, and associated morbidqual-ity from harvesting cannot be neglected As Li et al9 reported, bovine pericardium provides beneficial handling proper-ties The texture is solid but still flexible and does not require a composite structure with artificial material as

do other biocompatible grafts No special precautions appear to be warranted regarding thrombus induction,

Fig 2 Schematic view of the Y graft made from a 14-cm 

8-cm bovine patch (Vascu-Guard; Synovis Life

Technolo-gies, St Paul, Minn) The Y graft is formed from two single

tube grafts The needed circumference of the tube grafts

is calculated as the product of diameter andV according

to the circle formula In order to keep enough space for a

double-layer suture, an additional 6 mm should be added

to the calculated size, or more easily, the graft can be cut

and sewn over a 9-mm Hegar dilator The suture (Prolene

4-0; Ethicon/Johnson & Johnson, Somerville, NJ) is a

double-layer closure with a horizontal mattressfirst and

then a second over-running suture The over-running

su-ture should not catch thefirst suture to avoid stitch-hole

tearing The suture is started at the middle, the distal

end is tied, and the proximal end is left open for distance

ofw4 cm to form the crotch and the main body

Begin-ning from the crotch, where the two legs are tied together,

the anterior and posterior face of the trunk are formed by

a running suture As shown in the right leg, length

adjustment can easily made in situ through eversion of

the prosthetic limb The maximum length of the

bifur-cated graft is 14 cm, and the length of the main body and

the diameter are variable; in our example, the main body

was 4 cm long and the diameter of the leg was 9 mm

Fig 3 Intraoperative view of the implanted infrarenal bovine pericardial Y graft

Volume 2, Number 4

because bovine patches used in carotid surgery

deliv-ered results similar to those of venous grafts.10Although

technical success can be achieved in most cases, no data

exist thus far about the long-term results of bovine grafts,

and thorough follow-up is needed in these patients

along with prospective data about this concern.

CONCLUSIONS

Because of their off-the-shelf availability, handling

properties, and adjustability, self-made bovine

pericar-dial grafts are a useful option in urgent reconstruction

of vascular infections.

The authors thank Mrs Dorothea Mews-Zeides for

creating the artwork.

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December 2016