PMC8077032_01
Pre-operative computed tomography and fluorodeoxyglucose (FDG) positron emission tomography. (A, B, D) All three locations had clear elevations in maximum standard uptake value (SUVmax) and tissue to background ratio with focal FDG accumulation in the graft. (C) The proximal part of the graft, located in the para-renal segment, appears to be free from focal FDG accumulation (A, B, D) While the mid and distal part of the graft show clear signs of infection.
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Computed tomography angiography (CTA) revealed a collection around the aortic graft bifurcation, and positron emission tomography (PET) revealed increased 18F-fluorodeoxyglucose (FDG) uptake at this level (Fig. 1), confirmed by labelled WBC scintigraphy. The left renal artery was transected at the distal end of the bridging stent and a thoracorenal bypass was performed using a non-ringed 7 mm diameter Synergy antimicrobial graft (AMG) (Getinge, Bensheim, Germany) to limit the left renal warm ischaemia time to 25 minutes (Fig. 3A 1).
Explantation of the fenestrated endograft. (A) Picture of the aorto-enteric fistula (arrowhead) and the important local inflammation responsible for increased difficulty in surgical debridement. (B) Thoracic aorta to left renal bypass with an antimicrobial graft performed before explantation (upper arrowhead), and explantation of the limbs first by unplugging the distal modules (lower arrowhead). (C) Explantation of the left renal stent graft (arrowhead). (D) Explantation of the right renal stent graft (arrowhead) and perfusion of the right kidney using a 4 C Ringer lactate solution. (E) Explantation of the barbs and the hooks of the fenestrated graft by squeezing the upper stent and gently pushing the stent hooks in a proximal direction (arrowhead). (F) Complete explantation of the fenestrated module.
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Dissection was difficult near the graft attachment sites, with a reactive process similar to that encountered in inflammatory aneurysms, especially near the right iliac artery, revealing a small bowel fistula (Fig. 2) with enteral leak and peri-graft collections without clear purulence. In situ reconstruction was accomplished with a bifurcated AMG of 20/10 mm diameter sutured just below the SMA with a warm ischaemic time of 30 minutes for both visceral arteries (Fig. 3A 2 and 3C).
Reconstruction with an aorto-bi-iliac antimicrobial graft. (A) Sketch of the aortic reconstruction, always recorded in the patient's files: (1) left thoracorenal bypass using a 7 mm diameter antimicrobial graft to limit left renal warm ischaemia time to 25 minutes; (2) cross clamping of the thoracic aorta above the coeliac trunk and below the thoraco-renal bypass to perform complete excision of grafts and debridement of devitalised tissue while perfusing the right kidney using a 4 C Ringer lactate solution. In situ reconstruction with a bifurcated antimicrobial graft of 20/10 mm in diameter sutured below the superior mesenteric artery, with a warm ischaemic time of 30 minutes for the coeliac trunk and superior mesenteric artery; (3) direct re-implantation of the right renal artery into the main body after one hour of cold ischaemia; (4) distal anastomoses on both external iliac arteries. (B) Proximal aortic anastomosis performed below the superior mesenteric artery and the coeliac trunk (identified with the two upper red silastic slings) but above the renal arteries, using an antimicrobial bifurcated graft. (C) Cross clamping of the right renal artery just before performing its re-implantation. (D) Re-implantation of the right renal artery to the main body of the aortic graft.
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The left renal artery was transected at the distal end of the bridging stent and a thoracorenal bypass was performed using a non-ringed 7 mm diameter Synergy antimicrobial graft (AMG) (Getinge, Bensheim, Germany) to limit the left renal warm ischaemia time to 25 minutes (Fig. 3A 1). The right renal bridging stent was gently avulsed, and the right kidney was perfused using 4 C Ringer lactate solution (Fig. 3B). In situ reconstruction was accomplished with a bifurcated AMG of 20/10 mm diameter sutured just below the SMA with a warm ischaemic time of 30 minutes for both visceral arteries (Fig. 3A 2 and 3C). The right renal artery was re-implanted in the main body after one hour of cold ischaemia (Fig. 3A 3 and 3D). Distal anastomoses were performed to both external iliac arteries (the right hypogastric artery had been ligated 12 years previously and the left was ligated during this procedure) (Fig. 3A 4).
Graph of the evolution of the inflammatory biological syndrome. (A) Evolution of the C reactive protein before and after explantation. (B) Evolution of leucocytosis before and after explantation.
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Distal anastomoses were performed to both external iliac arteries (the right hypogastric artery had been ligated 12 years previously and the left was ligated during this procedure) (Fig. 3A 4). Eleven months later, the patient was free from re-infection (CRP: 13 mg/L, WBC: 6.7 x 109/L, Fig. 4), with normalised renal function (70 mL/min/1.73 m2), good general condition, a patent reconstruction (Fig.