Homografts for mycotic aneurysms and infected grafts:

Summary of techniques and outcomes

Olaf Richter, Silvio Rohm

Ev. Diakonissenkrankenhaus Leipzig Dept. of Vascular Surgery

Ev. Diakonissenkrankenhaus Leipzig Akademisches Lehrkrankenhaus der Universität Leipzig

Ev. Diakonissenkrankenhaus Leipzig Akademisches Lehrkrankenhaus der Universität Leipzig Eine Einrichtung der edia.con-Gruppe

Disclosure

Speaker name:

Olaf Richter, MD

I have the following potential conflicts of interest to report:

Consulting

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

Other(s)

I do not have any potential conflict of interest X

Incidence of aortic graft infection

0,2 % – 5 %

Therapeutic options

Long-term Antibiosis Terpling et al., Scand J Infect Dis. 2006;38(5):388-92 Turgut et al., BMC Infect Dis. 2005 Oct 21;5:91 Treitl M et al, Cardiovasc Intervent Radiol. 2011 Jun;34(3):642-6

Drainage Raffatto et al., J Vasc Surg. 2004 Oct;40(4):826-9. Lavage Voboril et al., Ann Vasc Surg. 2004 May;18(3):372-5. Francois et al., Ann Vasc Surg. 1991 Mar;5(2):199-201.

Muscle Flap Seify et al., Plast Reconstr Surg. 2006 Apr;117(4):1325-33. Mitra et al., Chest. 2005 Aug;128(2):1040-3. Schutzer et al., Vasc Endovascular Surg. 2005 Mar-Apr;39(2):159-62.

Cutis Flap Nenezic et al., Srp Arh Celok Lek. 2005 Jan-Feb;133(1-2):69-71.

Omentum plastic Van Krunckelsven et al., Eur J Vasc Endovasc Surg. 1995 Aug;10(2):256-7. Krabatsch et al., Eur J Cardiothorac Surg. 1995;9(4):223-5. Shah S, Sinno S, Vandevender D, Schwartz J., Ann Plast Surg. 2013 Jun;70(6):680-3

Fascial Flap Sarac et al., J Vasc Surg. 2003 Dec;38(6):1404-6.

Vacuum Therapy Dosluoglu et al., J Vasc Surg. 2005 Volume 42 (5):989-992 Mayer D, Hasse B, Koelliker J, Enzler M, Veith FJ, Rancic Z, Lachat M., Ann Surg. 2011 Nov;254(5):754-59

Adhesive Dressing Aksoy et al., Surg Today. 2006;36(1):52-6.

Vein Da Gama et al., Rev Port Cir Cardiotorac Vasc. 2004 Apr-Jun;11(2):101-5. Daenens et al., Eur J Vasc Endovasc Surg. 2003 Mar;25(3):240-5. Toursarkissian et al., Vasc Surg. 2001 Mar-Apr;35(2):157-61.

Silver prosthesis Bisdas T et al, J Vasc Surg. 2010 Aug; 52(2):323-30. Batt M et al, J Vasc Surg. 2003 Nov; 38(5):983-9.

Antibiotic prosthesis Aboshady I, Raad I, Shah AS, Vela D, Dvorak T, Safi HJ, Buja LM, Khalil KG., J Vasc Surg. 2012 Sep;56(3):794-801 Lew W, Moore W., Semin Vasc Surg. 2011 Dec;24(4):211-9

Arterial transplantation Kieffer et al., J Vasc Surg 2004, 1009-1017 Harlander-Locke et al., J Vasc Surg 2014, 669-74

-  Revision of the wound, lavage, antibiosis

-  Remove all prosthetic material

-  (Extraanatomic bypass)

-  In-situ-reconstruction

!  Desobliteration of own artery !  Autologous venous bypass !  Protheses !  Arterial homograft

Therapeutic options

History Arterial Transplantation

1908  Carrel, experimental research on artery replacement

1910  Pirovano, first unsuccessful human artery transplantation

1949 Gross, reconstruction of aortic defect 1950 Oudot, 1. reconstruction of an aortic bifurcation

1951 Dubost, 1. replacement of an aortic aneurysm

>1960 alloplastic graft

1988 Kieffer, reintroduction arterial homografting

Allograft replacement for infrarenal aortic graft infection: Early and late results in 179 patients (1988 – 2002)

-  Mean follow up 46.0 ± 42.1 months (1 - 148 m)

-  111 x fresh allograft (until 1996) 68 x cryopreserved allograft

-  Results: 30-d-mortality 20 % Late mortality 26 %

-  Rare specific complications (rupture, dilatation)

-  Late iliofemoral complication (63 x, most occlusive)

-  Complications reduced by using cryopreserved and no thoracic aortal allografts

Kieffer et al., J Vasc Surg 2004, 1009-1017

Fresh vs. Cryopreserved Homograft

-  n = 68 pat. -  Mean follow up 30 months (1 - 68) -  Prosthetic removal and In-situ-reconstruction: 11 x fresh homograft 57 x cryopreserved homograft

-  Results: 30-d-mortality 16 % (n = 11)

Late mortality 25 % (n = 17) Graft occlusion 16 % (n = 11)

-  No significant difference between fresh or cryopreserved graft -  No ABO- compatibility

Chiesa et al., Acta Chir Belg 2002, 238 - 47

Reinfection of homografts

-  n = 30 -  1/90 – 04/97 -  27 x in situ repair -  Mean follow up 24,5 months (2 – 60)

-  Results: 30-d-mortality 27 % (n = 8)

Late mortality 10 % (n = 3)

-  Persistant infection in 2 cases -  No ABO- compatibility

Nevelsteen et al., 1998, Cardiovasc Surg; 6:378-83

ABO-match for cryopreserved homograft

-  78 % (n = 22) ABO-compatible -  22 % (n = 6) non-ABO-compatible -  30-d-mortality 29 % (n = 8) -  Late mortality 25 % (n = 7) -  No statistical difference

-  n = 32 -  2004 – 2007 -  47 % (n = 15) ABO-compatible -  53 % (n = 17) non-ABO-combatible -  No statistical difference

Leseche et al, J Vasc Surg 2001, 616 - 22

Bisdas et al., Int Angiol 2011;30:247 - 55

T. S. Ikonen, J. F. Gummert, M. Hayase, Y. Honda, B. Hausen, U. Christians, G. J. Berry, P. G. Yock, R. E. Morris “Sirolimus (Rapamycin) halts and reverses progression of allograft vascular disease in non-human primates.” Transplantation 2000; 70: 969 - 975

Immunosuppression and aortic homograft

The use of cryopreserved aortoiliac allograft for aortic reconstruction in the United States

-  Multicenter study (14 inst.) n = 220 -  Mean follow up 30,0 ± 3 months (1 - 160) -  30-d-mortality 9 % -  Patient survival 75 % @1a, 51 % @5a -  Prim. patency (5a): 97 % -  Specific complications 24 %

-  Persistent sepsis (n = 17) -  CAA thrombosis (n = 9) -  CAA ruptur (n = 8) -  CAA reinfection (n = 8) -  CAA pseudoaneurysm (n = 6) -  Recurrence of aortoenteric fistula (n = 4)

J Vasc Surg. 2014 Mar;59(3):669-74

Own experience (n = 122 patients)

Vascular transplantation program 11/2000 – 02/2010 (University of Leipzig - UKL)

-  “Bridging“-OP -  n = 80 -  Fresh Homografts and immunosuppression -  „Gewebegesetz“ (7/2007 – federal law)

Vascular transplantation program 05/2010 until now (Diakonissen-Hospital Leipzig - DKL)

-  Cryopreserved allografts -  No immunosuppression

Aortic reconstruction

UKL DKL

Period 11/2000 - 02/2010 05/2010 - 01/2016

Follow up 23 (0 – 106) 20 (0 – 65)

Patients 48 27

Sex ♂ 43

♀ 5

♂ 20

♀ 7

Age 68 (50 – 81) 65 (46 – 80)

Allograft Fresh Cryo

Aortic reconstruction

UKL DKL

Aortic tube 5 0

Aortobiiliacal 5 2

Aortobifemoral 29 22

Aortomonofemoral 9 3

Infected material

Prosthetic graft 46 27

EVAR graft 2 0

Organism

gram-positive gram-negative

11 x Enterococcus 11 x Staphylococcus aureus 5 x MRSA 7 x Staph. epidermidis 3 x Streptococcus

5 x E. coli 2 x Prevotella 2 x Enterobacter 2 x Salmonella typhimurium 2 x Bacteroides fragilis 1 x Proteus mirabilis 2 x Pseudomonas aerogiosa 1 x Candida albicans 5 x others

Gastroscopy

Gastroscopy Dr. Stephan

Dres. med. Bayer, Schmidt, Steinecke, Englisch, Neubauer, Löbe, Schneider, Häntschel, Scholle, Schäfer

by courtesy of

Results

UKL(fresh) DKL(cryo)

Mortality < 30 d n = 5 (10,4 %) d - 7, 12, 18, 25, 25

n = 5 (18,5 %) d - 0, 0, 2, 13, 17

Mortality > 30 d n = 14 (29,1 %) n = 5 (18,5 %)

Bypass thrombectomy 8 4

Chronic bypass occlusion 1 0

Ureteroiliac fistula 0 1

Graftinfection 1 1

Rejection 0 0

Stenosis 1 0

Aneurysm 0 1

Σ complications 11(22,9 %) 7 (25,9 %)

Results

UKL(fresh) DKL(cryo)

Mortality < 30 d n = 5 (10,4 %) d - 7, 12, 18, 25, 25

n = 5 (18,5 %) d - 0, 0, 2, 13, 17

Mortality > 30 d n = 14 (29,1 %) n = 5 (18,5 %)

Bypass thrombectomy 8 4

Chronic bypass occlusion 1 0

Ureteroiliac fistula 0 1

Graftinfection 1 1

Rejection 0 0

Stenosis 1 0

Aneurysm 0 1

Rupture /Bleeding 3 6

Σ complications 14 (29,1 %) 13 (48,1 %)

Patient survival and primary patency

2015

1) Graft enteric fistula

Fresh Allograft: n = 7 (14,6 %)

Cryopreserved: n = 6 (22,2 %)

2) Quality of the allograft

3) Aneurysm

15.09.2014 (8 month after transplantation)

Dres. med. Bayer, Schmidt, Steinecke, Englisch, Neubauer, Löbe, Schneider, Häntschel, Scholle, Schäfer

Gastroscopy Dr. Thies

by courtesy of

3) Aneurysm

EVAR (16.09.2014)

Dres. med. Bayer, Schmidt, Steinecke, Englisch, Neubauer, Löbe, Schneider, Häntschel, Scholle, Schäfer

CT PD Dr. Schneider

by courtesy of

3) Aneurysm

EVAR / HOMOGRAFT – EXPLANTATION (12.05.2015)

3) Aneurysm

EVAR / HOMOGRAFT – EXPLANTATION (12.05.2015)

3) Aneurysm

EVAR / HOMOGRAFT – EXPLANTATION (12.05.2015)

3) Aneurysm

EVAR / HOMOGRAFT – EXPLANTATION (12.05.2015)

4) Ureteroiliac fistula

UKL, Dept. of Radiology Dr. P. Stumpp

by courtesy of

Summary

-  Mortality rate is moderate

-  Most complications in the early postop. periode (persistent infection)

-  Better results with fresh allografts and immunosuppression (?)

-  „Bridging“ therapy " long-term therapy

-  Homografts „should be considered a first line therapy of aortic

infection

Homografts for mycotic aneurysms and infected grafts:

Summary of techniques and outcomes

Olaf Richter, Silvio Rohm

Ev. Diakonissenkrankenhaus Leipzig Dept. of Vascular Surgery

Ev. Diakonissenkrankenhaus Leipzig Akademisches Lehrkrankenhaus der Universität Leipzig

Ev. Diakonissenkrankenhaus Leipzig Akademisches Lehrkrankenhaus der Universität Leipzig Eine Einrichtung der edia.con-Gruppe