Vascular Complications and Hemodialysis

Vascular Complications and Hemodialysis

0800–1030 Room: Miramar 2 Wednesday, September 12, 2001 PII: S0967-2109(01)00073-4 Session XIII Vascular Complications and Hemodialysis Co-Chairmen:...

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0800–1030 Room: Miramar 2

Wednesday, September 12, 2001 PII: S0967-2109(01)00073-4

Session XIII Vascular Complications and Hemodialysis Co-Chairmen: J.F. Gurry, Australia; Dino Sfacich, Argentina 13.1 A Prospsective, Multicenter Audit of Complex Vascular Wound and Graft Infections—The Impact of MRSA P.D. HAYES, S. DARKE and A.R. NAYLOR, Great Britain and Ireland Background: Many studies have looked at the outcome of vascular infections, but they often contain small numbers of cases collected over a long period of changing practise. Between Feb ’98 and Jan ’99, this multicentre audit was performed in to examine the outcomes of complex infections in vascular surgery, with particular reference to MRSA. Wound infections: 66 grade II or III Szilagyi wound infections occurred. No vein grafts became infected versus 12 of 38 prosthetic grafts (p−0.01). MRSA accounted for 41.6% of infections and was present in 67% of cases with adverse outcomes. Adverse events occurred in 32% of MRSA+ cases and in 10% of MRSA- cases (p−0.04). Wound infection proceeded to graft infection in 58% of MRSA+ cases and in 32% of MRSA- cases (p−0.08). Median length of stay was 31 days for MRSA+ versus 18 days for MRSA- (p=0.001). Graft infections: 43 graft infections occurred. Median time to presentation was 39 days (range 2–2450 days). There were 16 deaths and 9 major limb amputations. MRSA infections were present in 36% of all graft infections. MRSA infection occurred more frequently where the primary procedure had been an urgent procedure rather than an elective case (p−0.03). MRSA graft infection accounted for 78% of all the major limb amputations. The median length of stay in the MRSA+ patients was 25 days longer (p−0.001). Conclusions: MRSA infection is now the most common organism involved in complex infections following vascular procedures. It is associated with an increase in the number of adverse outcomes and significant increases in lengths of stay.

AVF. Graft was used as a last resort n=30 (5.8%) seventeen forearm graft were performed compared to 13 at the arm level. Permicath was inserted in 6 cases after failure of all of the previous procedures and/or in-patient with limited life span. The cumulative early failure rate was 19.5% and that was the commonest complication. Other uncommon complication included: 14(2.7%) aneurysms, 6 (1.1%) steal, 3 (0.6%) bleeding and another 0.6% venous hypertension. To minimize the complication rate, angioaccess construction should not be considered as a minor surgical procedure. Ideally, it should be executed and/or supervised by the surgeons who are versed in them together with their follow-ups.

13.3 The Management of Shaggy Aorta Syndrom (SAS) N. HAYASHIDA, H. MURAYAMA, K. MATSUO, Y. PEARCE, S. ASANO, Y. OHASHI, H. KOHNO, T. HANDA, Y. NAKAGAWA and K. TATSUNO, Ichihara, Chiba, Japan Introduction: The SAS is a rare disorder causing peripheral, renal and visceral ischemia resulting from multiple cholesterol emboli from the aorta. We have experienced 4 cases of SAS for 2 years. The diagnosis and treatment of SAS from the experience of these 4 cases will be discussed. Conclusion: (1) Early diagnosis is crucial in SAS; (2) An enhanced CT should be performed prior to intra-arterial catheterization if SAS is suspected; (3) Intravenous digital subtraction aortography may be a useful diagnostic procedure; (4) If diagnosis of SAS is established, anticoagulation therapy should be discontinued.

13.2 Angioaccess in Chronic Renal Failure Patients: Review of 517 Cases H. AL-ZAHRANI, R. JAMJOOM, S. AL GHAMDI and S. AL SHOHAIB, Jeddah, Saudi Arabia

13.4 Infected Femoral False Aneurysms J. GURRY, S. GETT, M. DENTON, J. VIDOVICH and M. LOVELOCK, Melbourne, Victoria, Australia

Over 8 years period starting January 1993 a total of 517 angioaccess procedures were performed for haemodialysis patients. Three hundred and ninety nine (75.8%) of the total was conventional radiocephalic anteriovenous fistula AVF. The second common procedure was an antecubital AVG n=63 (12.1%). Other direct fistula were undertaken in the forearm n=26. That included 9 (1.7%) radiocephalic, 9 (1.7%) ulno-basilic and 8 (1.5%) forearm in-situ

Over the past two years we have managed thirteen infected femoral false aneurysms. Although historically these have been associated most often with anastomotic aneurysms following surgery, this is no longer the case, and the aneurysms we have encountered have been largely associated with either previous coronary angioplasty and/or intervention, or alternatively chronic substance abuse. Of the thirteen femoral false aneurysms managed by us, one was associated with a

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25th World Congress of the ISCVS previous aortobifemoral graft, five have followed cardiac intervention and the other seven were related to intravenous drug abuse. Staphylococcus aureus was the causative organism in all cases. There was no mortality in the group treated and no limb loss. Bypass grafting was performed around the infected aneurysm in seven cases, the aneurysm was oversewn in three cases and in three cases an in situ reconstruction of the vessel was performed. Postoperative average length of stay was thirty days, and complications included rebleeding requiring further surgery in three cases, and femoral nerve palsies in two. The cases are presented in detail, and options for surgical management discussed.

well to the ePTFE graft. Postoperatively, mean flow rate through the graft was 444 mL/minute. All patients received antiplatelet therapy, and all became and remain asymptomatic. With a follow-up period of up to 6 years (mean 3.4), all bypasses are patent and functioning well. The hanging position of the graft has not produced any pulling down of the pedicle with the renal vessels. No stenoses or deformities of the bypass have been observed angiographically. This new bypass method appears to be safe and durable.

13.5 Iatrogenic Vascular Trauma G. ROJAS and J. CERVANTES, Mexico City, Mexico From June 1987 to September 2000, we treated 35 patients (29 adult and 6 pediatric) that suffered iatrogenic vascular lesions (IVL). Mechanism of trauma: 15 cases (42.85%) secondary to vascular access and catheterizations, 10 (28.57%) during orthopedic surg. (lumbar laminectomy 4, fuxation fx. Femur 4, knee arthroscopy 1, etc.), 5 (14.28%) in general surgery (resect. retroperit. tumor 2, inguinal hernia repair 1, Rt. hemicolectomy 1, etc.) and 5 (14.28%) during gynecologic surg. (abd. histerectomy 3 and pelvic laparoscopy 2). There were 28 (77.77%) arterial lesions (femoral 9, iliac 5, brachial 3, etc.) and 8 (22.22%) venous (common iliac 2, inferior v. cava (IVC) 2, hypogastric 2, etc.) Clinical presentation: thrombosis/ischemia 14 cases (40%), hematoma/bleeding 12 (34.28%), pseudoaneurysm 6, (17.14%), A/V fistula 6 (5.71%) and the presence of foreign body 1 (2.85%). Results: Mortality 2 patients (5.71%), massive bleeding in 1 due to IVL of the IVC during lumbar laminectomy and reperfusion injury post-repair of a IVL of the femoral artery during fixation fx. femur. Operative morbidity 5 patients (14.28%): 2 major amputations (1 A/K and 1 of 4 fingers), 2 neuropraxic lesions (hypoglossal and sciatic) and 1 ureteral lesion. Conclusions: IVL are becoming a more common problem that causes major disability and death. Its treatment by a qualified vascular team is mandatory.

13.6 Aorto-Superior Mesenteric Artery Bypass Using a New Route T. IWAI,Y. INOUE, N. SUGANO, M. HIROKAWA, T. KUDO, N. KURIHARA, N. NAKAMURA and E. NAKAJIMA, Tokyo, Japan Symptomatic lesions of the chronic superior mesenteric artery (SMA) are rare in Asian countries. However, we recently treated 5 patients (4 women, 1 man; mean age, 59 years) who had such a lesion, which was causing subacute occlusion or aneurysm. Patients with occlusion had abdominal angina or ischemia mucosal changes such as colonic ulcers. Two patients with aneurysm had severe continuous abdominal pain. We developed an aorto-SMA bypass in which anastomosis is done first between the infrarenal aorta or internal iliac artery and a Y graft, and then the graft is brought up behind the pedicle of the renal vessels, turned forward, and anastomised to the SMA (Figure). This bypass provides a good angle for natural antegrade blood flow to the SMA, and the renal pedicle fixes

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13.7 Early Transposition of the Sartorius Muscle for Exposed Patient Infrainguinal Bypass Grafts E. ASCHER, A. HINGORANI, Y. GUNDUZ and S. KALLIKURI, Brooklyn NY, USA Objective: The traditional approach for patent and exposed and infected infrainguinal bypass grafts in the groin has included wide operative debridement and secondary or delayed primary closure. However, this has been associated with significant risk of further contamination and length of stay. We reviewed our experience using the wide debridement, the sartorius muscle flap transposition with primary wound closure as an alternative. Methods: During the last 4 years, our service has performed 821 procedures for lower extremity revascularization. Twenty-six of these (4%) have been complicated by major wound necrosis or infection in the groin or thigh with the graft or native artery being exposed after debridement. The age of these patients ranged from 51–90 years (mean 73 years). Fifty-two percent of these patients were diabetics. Five of these patients had undergone six prior attempts to close the wounds. These 31 wound complications occurred after thirteen lower extremity revascularizations with PTFE, and 13 with vein. Two of these had prior revascularization attempts. After wide debridement, closure was performed by the vascular surgeon using the sartorius muscle flap. Results: Postoperatively, two patients required further debridement of the overlying skin. One patient had necrosis of the flap that needed debridement of the flap. Two necessitated drainage of seroma. One patient had developed a pseudoaneurysm five weeks after placement of the flap and removal of the infected PTFE. This patient underwent ligation of the common femoral artery. None have

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25th World Congress of the ISCVS resulted in further systemic or graft sepsis. None have resulted in arterial or graft blow-out. None of the grafts have closed. Postoperative hospital stay ranged from 2–39 days (mean 14 days). Followup ranged from 1–27 months with a mean of 8 months. Conclusions: Closure of groin and thigh wounds with exposed bypass graft or native artery can be safely performed with the sartorius muscle flap with excellent results. The length of stay of these patients compared to historical controls is acceptable. Furthermore the chance of infection of the native artery or bypass may be reduced. Familiarity with this simple technique can be a valuable tool in the armamentarium of the vascular surgeon.

13.8 Vascular Involvement in Behcet’s Disease— Experience of King Khalid University Hospital, Riyadh, Saudi Arabia M.M.S. AL-SALMAN, Riyadh, Saudi Arabia Behcet’s disease is a chronic, inflammatory, multisystem disorder characterized by widespread vasculitis of both large and small arterial and venous vessels. Four types of vascular lesions are recognized: arterial and venous occlusion, aneurysm, and variceal development. The disease is common in the Mediterranean basin, and Japan, where it affects up to 1 in 1000 individuals, in contrast to the United States and United Kingdom where the incidence of disease is 1 to 5 per 100,000. The cause of Bechet’s disease is unclear, but it is believed that the pathological process affecting the large arteries is due to immune complex deposition in small vessels that results in complement fixation and neutrophil activation. This process potentially releases lysosomal enzymes and oxygen-free radicals, thereby damaging the endothelial cells of the vessel walls. Transmural necrosis of the walls of the larger arteries occurs when the vasovasorum is occluded. Weakening of the degenerated vessel wall produces aneurysms: perforation of the vessel wall forms pseudoaneurysms. We report our experience at KKUH (Saudi Arabia) 65 patients with vascular involvement, 17 arterial and 48 venous. The male to female ratio is 3.3:1 (50 males and 15 females). In the arterial group (17 patients), there were 7 patients with additional venous involvement. While the venous group (48 patients), there were six patients with additional arterial involvement. The vascular involvement ranged from arterial aneurysm and occlusion, while the venous involvement includes aneurysm and thrombosis. The full detailed investigation, type of arterial, and venous involvement with their management and mortality will be discussed.

up for 4–42 (mean 17) months to assess wound healing, graft patency and hospital stay. Results: All patients had excellent direct wound healing. No patients presented with recurrence of infection or manifestations suggesting muscle necrosis. The mean hospital stay was 13 days (ranged from 10 to 19 days). Conclusion: Sartorius myoplasty is useful in eradicating infection from infected groin with prothetic graft and can decrease the hospital stay when carefully performed and small sized wounds are selected. Key Words: infected, grafts, sartorius, myoplasty, groin

13.10 Immunocytochemical and Morphometric Analysis of Arteriovenous Maturation J.C. CHEN, B.A. ALLISON, A. PATEL and Y.N. HSIANG, Vancouver, B.C., Canada Purpose: Autogenous arteriovenous fistulae (AVF) are the preferred method of vascular access for chronic hemodialysis patients. However, approximately 15% of AVF fail to mature for adequate hemodialysis. The purpose of this study was to examine the remodeling process following fistula creation to identify features that may predict maturation failure. Methods: AVF were created between the internal jugular vein and common carotid artery in 38 male swine aged 6 to 8 months. Swine were sacrificed one month later and their AVF perfusion-fixed with 10% formalin. Serial sections were taken from the anastomosis and at 1 cm intervals to 5 cm from the anastomosis. Intimal and medial thickness was determined by morphometry. In addition, the specimens were stained for elastin, ␣-actin, and MMP-9 (0–3 scale). Results: The thrombosis rate varied according to size of the jugular vein (100% with vein diameters <2 mm, 30% vein diameters >2 mm). Four types of AVF were apparent histologically. These were: AVF with thick walls and large diameters (Group 1), thick walls and small diameters (Group 2), thin walls and large diameters (Group 3), and thin walls and small diameters (Group 4). The morphometric and immunocytochemical results were as follows: Group

Intimal thickness (mm)

Medial thickness (mm)

MMP-9 (intima)

MMP-9 (media)

1 2 3 4

.45 ± .21 .45 ± .17 .13 ± .12 .08 ± .14

.65 ± .21 .85 ± .17 .42 ± .12 .32 ± .14

1.5 .30 0 0

1.0 .60 1.1 0

Conclusions: Following AVF creation, both intimal and medial hypertrophy contributes to vessel wall thickness. MMP-9 staining was seen primarily in thick walled veins.

13.9 Sartorius Myoplasty for Groin Infections Following Prosthetic Vascular Graft H.M. RABEE FRCS, Riyadh, Saudi Arabia Background: This study reports experience with sartorius myoplasty in the management of groin prothetic graft infection. The procedure was used only in early infected small sized groin wounds with very limited interruption of its blood supply. Patients and methods: Between February 1994 and February 1999 nine patients underwent sartorius myoplasty (six women and three men of mean 56 (range 25–72) years). All cases were followed

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3.11 The Use of Cryopreserved Femoral Vein in the Treatment of Infected Hemodialysis Grafts J. MATSUURA, D. ROSENTHAL, M. CLARK, R. SHARMA, Atlanta, GA, USA Purpose: As the number of renal failure patients continues to increase, prosthetic hemodialysis graft infection is a significant prob-

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25th World Congress of the ISCVS lem. We are reporting our four year experience with the cryopreserved femoral vein in the treatment of infected prosthetic arteriovenous (AV) grafts. Methods: Between August 1996 and August 2000, 43 patients presenting with prosthetic AV graft infections treated with prosthetic graft excision and immediate replacement with cryopreserved femoral vein were prospectively evaluated. All grafts were used for hemodialysis between 10–14 days postoperatively. Patients survival and graft patency were calculated using Life Table analysis. Results: The mean age was 54 years (range 25–75) and 58% were males. The mean follow-up was 342 days (range 120–1460). There

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was one death within 30 days of surgery related to complications of sepsis. The 12-month mortality rate was 39%. One graft was excised at 90 days for recurrent infection. One patient developed arterial steal requiring a banding procedure. The 12-month and 24-month primary patency rates were 44% and 30% respectively. The 12-month and 24-month secondary patency rates were 72% and 65% respectively. Conclusion: With only one case of recurrent infection, our observations support the resistance of the cryopreserved femoral vein to bacterial infections. The cryopreserved femoral vein is a safe durable alternative for the treatment of prosthetic AV graft infections.

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