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Infection of arterial graft — Clinical Guidelines

Overview

Infection of arterial grafts is a serious complication following vascular bypass surgery, often necessitating graft explantation and replacement, particularly with cryopreserved allografts in cases of prosthetic graft infections 1 2.

Diagnosis

Clinical signs include fever, local inflammation, and graft aneurysmal deterioration 1.

Imaging modalities such as Doppler ultrasound and angiography can identify graft abnormalities and infection spread 1 15.

Histological examination of explanted grafts reveals inflammatory cell infiltration, pseudoaneurysms, and necrosis 1.

Management

First-line Treatment: Removal of the infected graft and appropriate antibiotic therapy tailored to the causative organism 7 13.

Graft Replacement: Cryopreserved allografts are used for replacement, especially in cases of recurrent infections 1 2.

Adjunctive Therapies: Thromboxane receptor antagonists like vapiprost may reduce thrombogenicity in experimental settings 6.

Platelet Inhibition: Combination therapy with aspirin and dipyridamole can decrease platelet deposition on Dacron grafts 14 17.

Special Populations

Elderly: Surgical intervention may be deferred in favor of intensive antibiotic therapy due to comorbid conditions 7.

Comorbidities: Severe comorbidities like congestive heart failure and hypothyroidism may influence the decision to proceed with surgical reconstruction 7.

Key Recommendations

Explant Infected Graft and Initiate Targeted Antibiotic Therapy: Essential for managing arterial graft infections, especially in high-risk patients 7 (Evidence: Strong).

Use Cryopreserved Allografts for Graft Replacement: Effective for infected graft scenarios, emphasizing long-term durability 2 (Evidence: Moderate).

Consider Platelet Inhibition with Aspirin and Dipyridamole: To reduce thrombogenicity and improve graft patency in Dacron grafts 14 17 (Evidence: Moderate).

References

1 Soquet J, Chambon JP, Goffin Y, Jashari R. Acute rejection of a cryopreserved arterial homograft. Cell and tissue banking 2015. link 2 McCready RA, Bryant MA, Fehrenbacher JW, Beckman DJ, Coffey AC, Corvera JS et al.. Long-term results with cryopreserved arterial allografts (CPAs) in the treatment of graft or primary arterial infections. The Journal of surgical research 2011. link 3 Cameron BL, Tsuchida H, Connall TP, Nagae T, Furukawa K, Wilson SE. High porosity PTFE improves endothelialization of arterial grafts without increasing early thrombogenicity. The Journal of cardiovascular surgery 1993. link 4 Fujitani RM, Mills JL, Taylor SM. The "blue-toe" syndrome as a harbinger of impending infrainguinal vein graft failure: a report of three cases. Annals of vascular surgery 1993. link 5 Noishiki Y, Yamane Y, Tomizawa Y, Okoshi T, Satoh S, Kosuge T et al.. A method to reduce thrombogenicity of a graft for small diameter arterial substitution seeded with autologous venous tissue fragments. ASAIO journal (American Society for Artificial Internal Organs : 1992) 1992. link 6 Lundell A, Bergqvist D, Leide S, Lindblad B, Ljungberg J. The effect of a thromboxane receptor antagonist on acute ePTFE arterial graft thrombogenicity--an experimental study in sheep. European journal of vascular surgery 1991. link80516-x) 7 Kaufman JL, Smith R, Capel GC, Shah DM, Chang BB, Leather RP. Antibiotic therapy for arterial infection: lessons from the successful treatment of a mycotic femoral artery aneurysm without surgical reconstruction. Annals of vascular surgery 1990. link60845-5) 8 Rumisek JD, Wade CE, Kaplan K, Okerberg CV, Corley JH, Barry MJ et al.. The influence of early surface thromboreactivity on long-term arterial graft patency. Surgery 1989. link 9 Christenson JT, Al-Huneidi W, Saleh RA. Distal embolisation from the surface of PTFE grafts in vivo and the effect of low molecular weight dextran. European journal of vascular surgery 1988. link80060-4) 10 Mahir MS, Hynd JW, Flute PT, Dormandy JA. Effect of defibrinogenation on the early patency rate of experimental small calibre arterial grafts. The British journal of surgery 1987. link 11 Clowes AW, Kirkman TR, Clowes MM. Mechanisms of arterial graft failure. II. Chronic endothelial and smooth muscle cell proliferation in healing polytetrafluoroethylene prostheses. Journal of vascular surgery 1986. link 12 Lannerstad O, Björck CG, Dougan P, Ericsson BF, Nilsson B, Bergqvist D. The acute thrombogenicity of a compliant polyurethane arterial graft compared with autologous vein. An experimental study in sheep. Acta chirurgica Scandinavica 1986. link 13 Trout HH, Kozloff L, Giordano JM. Priority of revascularization in patients with graft enteric fistulas, infected arteries, or infected arterial prostheses. Annals of surgery 1984. link 14 Kester RC. The thrombogenicity of Dacron arterial grafts and its modification by platelet inhibitory drugs. Annals of the Royal College of Surgeons of England 1984. link 15 Megerman J, Christenson JT, Hanel KC, Strauss HW, Abbott WM. Imaging vascular grafts in vivo with Indium-111-labeled platelets. Influence of timing on image interpretation. Annals of surgery 1983. link 16 Sottiurai VS, Yao JS, Flinn WR, Batson RC. Intimal hyperplasia and neointima: An ultrastructural analysis of thrombosed grafts in humans. Surgery 1983. link 17 Norcott HC, Goldman M, Hawker RJ, Rafiqi EI, Drolc Z, McCollum CN. Platelet inhibitory drugs: an in vivo method of evaluation in patients. Thrombosis and haemostasis 1982. link 18 Carson S, Demling R, Esquivel C, Talken L, Tillman P. Testing and treatment of arterial graft thrombosis. American journal of surgery 1981. link80023-2) 19 Kenny DA, Berger K, Walker MW, Robel SB, Boguslavsky L, Ray LI et al.. Experimental comparison of the thrombogenicity of fibrin and PTFE flow surfaces. Annals of surgery 1980. link 20 Reddy GS, Cliff WJ. Morphologic changes in arterial grafts in rabbit ears. Laboratory investigation; a journal of technical methods and pathology 1979. link

Infection of arterial graft