Fresh and cryopreserved arterial homografts in the treatment of prosthetic graft infections: experience of the Italian Collaborative Vascular Homograft Group.
Following the experience of cardiac surgeons with homografts in the treatment of infective aortic valve endocarditis, cardiovascular surgeons have investigated in situ revascularization by means of homografts in the management of vascular prosthetic graft infections. Preliminary results are encouraging, but their late fate in long-term follow-up and the influence of preservation techniques are still under investigation. This article reports the experience of the Italian Collaborative Vascular Homograft Group, with the use of fresh and cryopreserved arterial homografts for the treatment of prosthetic graft infections. Between March 1994 and December 1996, 44 patients with prosthetic graft infection were treated with homografts (13 preserved at 4 degrees C, 31 cryopreserved). The mean age of the patients was 65 years. Emergency surgical procedures were performed in eight patients (18%). Sepsis was diagnosed in 11 patients, aortoenteric fistula in 13, and false aneurysms in 10. Staphylococcus was the main cause of infection. The types of vascular reconstruction with homograft were: 32 aortobifemoral, 3 aortoaortic, 2 iliofemoral, 4 peripheral, and 3 axillobifemoral. Human lymphocyte antigen (HLA) and antibody (ABO) blood group system compatibility between donors and recipients was not respected. The mean duration of follow-up was 15 months (range 1-33). Clinical and duplex scanning evaluations were routinely performed. Computed tomography (CT) or magnetic resonance (MR) scanning or arteriography were performed on the basis of duplex scanning results. There were six deaths during the early postoperative period (30 days) with a mortality rate of 13.6%. During the follow-up there were five late deaths with a mortality rate of 11.4%. Eight patients had graft occlusion. Three cases were successfully treated with thrombectomy. Two cases were successfully treated with femoropopliteal bypass with autologous vein. In three cases leg amputation was necessary. The results of fresh and cryopreserved homograft were compared. No significative differences of early postoperative mortality, late mortality, homograft related mortality, and graft occlusion were observed. We have evaluated the actuarial survival of the patients and the actuarial patency of the homografts on the aortoiliac reconstructions. Twelve months after the surgery the actuarial survival of the patients was 73% and the actuarial patency of the homografts was 56%. In our preliminary experience, we have not observed any significant difference in terms of clinical outcome by using fresh rather than cryopreserved homografts. In the near future it will be our policy to employ only cryopreserved homografts. Moreover, we will extend vessel harvesting to nonheart-beating donors, thus maximizing retrieval. The aforementioned solutions will supply the best graft availability to obtain dimensional and ABO compatibility between donors and recipients.
Chiesa
R
R
Divisione di Chirurgia Vascolare, IRCCS Ospedale S. Raffaele, Milan, Italy.
Astore
D
D
Piccolo
G
G
Melissano
G
G
Jannello
A
A
Frigerio
D
D
Agrifoglio
G
G
Bonalumi
F
F
Corsi
G
G
Costantini Brancadoro
S
S
Novali
C
C
Locati
P
P
Odero
A
A
Pirrelli
S
S
Cugnasca
M
M
Biglioli
P
P
Sala
A
A
Polvani
G
G
Guarino
A
A
Biasi
G M
GM
Mingazzini
P
P
Scalamogna
M
M
Mantero
S
S
Spina
G
G
Prestipino
F
F
D000328:Adult; D000368:Aged; D001158:Arteries / Q000637:transplantation*; D001807:Blood Vessel Prosthesis / Q000009:adverse effects*; D015925:Cryopreservation; D005260:Female; D006801:Humans; D007558:Italy; D008297:Male; D008875:Middle Aged; D016459:Prosthesis-Related Infections / Q000601:surgery*; D014184:Transplantation, Homologous; D016896:Treatment Outcome; D014654:Vascular Patency