BACKGROUND: Infected aortic grafts and mycotic aneurysms represent one of the most complex challenges faced by vascular surgeons. Treatment has progressed from extra-anatomical bypass to in situ reconstruction. Additionally, bovine pericardium reconstruction (BPR) has increased, due to accessibility and reduced lower limb morbidity. There remains, however, limited evidence for its use. The aim is to pool all known data to understand outcomes following BPR of mycotic aneurysms or infected vascular grafts.
METHODS: A systematic review was conducted in November 2021 with subsequent computerized meta-analysis of the pooled results and a final search in March 2022. Three databases, Excerpta Medica dataBASE (EMBASE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), and National Institutes of Health PubMed (PubMed), were searched for the search term \"(bovine OR xenoprosthetic) AND (aneurysm)\", according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
RESULTS: From 9 studies, there were 133 patients: 67% graft infections and 33% mycotic aneurysms. Fifty-seven percent of reconstructions were in the abdominal aorta and 33% were in the thoracic aorta. One hundred fifty-eight pathogens were identified, including Staphylococcus aureus (23%), Candida albicans (13%), and Escherichia coli (13%). In 12%, no microorganisms were identified. Thirty-day mortality was 19.14% (CI 10.83-28.71), late mortality was 19.08% (confidence interval [CI] 7.76-32.83), and overall mortality was 40.20% (CI 29.82-50.97). One patient died intraoperatively. There were a total of 151 in-hospital complications after 30 days postoperation. Common complications were acute renal failure (17%), pneumonia (14%), delirium (12%), respiratory insufficiency (11%) and renal insufficiency (7%). Lower limb ischemia was low, occurring in 5.66% (CI 0.54-13.82) of patients. Loss of graft patency leading to reintervention occurred in 1.20% (CI 0.00-7.71) of the grafts. Reinfection rate was 0.00% (CI 0.00-1.21).
CONCLUSIONS: This meta-analysis highlights low reinfection and high graft patency using BPR with medium-length follow-up; however, there remain limited long-term and comparative data regarding options for aortic reconstruction. As expected in this complex cohort, the complication rate and 30-day mortality remain high.

BACKGROUND: This review synthetizes recent literature about in-situ aortic reconstructions for abdominal aortic graft or endograft infections (AGEIs), aiming to report outcomes individually related to currently available vascular substitutes (VSs).
METHODS: We performed a systematic review of all published literature from January 2005 to December 2022. We included articles reporting on open surgical treatment of abdominal AGEIs, with removal of the infected graft and in-situ reconstruction with biological or prosthetic material. Articles not distinguishing between abdominal and thoracic aortic-related outcomes were excluded, as well as studies reporting on cumulative in-situ and extra-anatomic reconstruction results.
RESULTS: Of 500 records identified through database searching (Pubmed: 226; Embase: 274), 8 of them were included in the present review. Overall, 30-days mortality rate was 8.7% (25/285), while the most frequent early complications were respiratory adverse events (46/346, 13.3%) and renal function deterioration (26/85, 30%). In 250/350 cases (71.4%), a biological VS was utilized. In 4 articles, the outcomes of different types of VSs were presented jointly. Patients analyzed in the remaining 4 reports were sorted in a \"biological\" and a \"prosthetic\" group (BG and PG). The cumulative mortality rate of the BG and PG were 15.6% (33/212) and 27% (9/33), respectively, while graft reinfection was 6.3% (15/236) in the BG, and 9% (3/33) in the PG. The cumulative mortality rate reported in articles focused on autologous veins was 14.8% (30/202), while their 30-days reinfection rate was 5.7% (13/226).
CONCLUSIONS: Since abdominal AGEIs are uncommon conditions, literature focused on direct comparison between different types of VSs is scarce, particularly when related to materials other than autologous veins. Although we found a lower overall mortality rate in patients treated with biological material or with autologous veins only, in recent reports prosthesis provide promising results in terms of mortality and reinfection rate. However, none of the available studies distinguish and compares different types of prosthetic material. Large multicenter studies are advisable, especially focused on different types of VSs and their comparison.

UNASSIGNED: Epithelioid angiosarcoma is a rare soft tissue sarcoma with a poor prognosis. We report two cases of patients who presented with a history of lower back pain, inflammatory signs and weight loss 5 and 6 years after endovascular aortic repair (EVAR) of an elective infrarenal abdominal aortic aneurysm (AAA). Imaging suggested graft infection but tissue samples revealed an epithelioid angiosarcoma. The objective is to report the clinical presentation, investigative modalities and immunohistochemical findings of an angiosarcoma after EVAR.
UNASSIGNED: Two cases are described of an angiosarcoma of the aorta after EVAR. A literature search using PubMed, Embase and Web of Science was performed in English about angiosarcoma after EVAR published between 2007 and 2021. Relevant reports were selected and analysed.
UNASSIGNED: Fifteen case reports were identified, including the current two cases. Time to tumour detection after EVAR ranged from 6 to 120 months with a mean interval of 68 months. Most patients underwent endovascular repair of an AAA (13/15). Males (13 male/2 female patients) were predominant with a median age of 72 years (IQR 68-78 years). Over half of the patients had metastases at the time of diagnosis (9/15), most frequently in bones and liver.
UNASSIGNED: Diagnosis of angiosarcoma after EVAR remains challenging due to indistinctive clinical and radiological findings mimicking graft infection or endoleak. Angiosarcoma should be included in the differential diagnosis in patients previously treated with EVAR presenting with unintended weight loss, abdominal back pain and contrast enhancement of the aortic wall.AbbreviationsAAAabdominal aortic aneurysmCTAcomputed tomography angiographyCRPc-reactive proteinEVARendovascular aortic repairESRerythrocyte sedimentation rateFDGfluoro-deoxyglucoseMRImagnetic resonance imagingMeSHmedical subject headings.

OBJECTIVE: Proximal aortic graft infection (PAGI) is a rare but often fatal postoperative complication. Its management often relied on surgical preferences and resource availability of each centre, until the recent unifying guidelines published by the European Society for Vascular Surgery (ESVS). This paper aimed to amalgamate the published experience in managing PAGI and their outcomes.
METHODS: PubMed, Scopus and Cochrane Library databases were searched systematically. All primary studies besides single-patient case reports were included. Data extracted included study and patient characteristics, type of index surgery, type of microorganisms involved, definitive treatment modality, and any outcome measures reported.
RESULTS: Of the 20 studies included, 157 of the 290 PAGI patients underwent complete graft explantation and replacement, 106 underwent graft-preservation interventions (debridement and/or irrigation), and 25 had antibiotics alone. Adjunctive interventions included graft coverage, vacuum-assisted closure, use of infection-resistant graft materials, and lifelong suppressive therapy. In-hospital mortality was 20.8% (n=60), with postoperative sepsis and multiorgan failure (n=24) being the most common cause. Recurrent infection occurred in 10 post-discharge patients. Post-discharge mortality rate was 11.4% (n=33), with cardiac complications and stroke being the most common cause in surgically-treated and medically-treated patients, respectively.
CONCLUSIONS: Given the risk of mortality, the management approach of PAGI highly depends on the fitness of the patient. We believe that early referral to specialised aortic centres is essential to plan for optimal management strategies and improve patient outcomes. Further studies are also required to parse out the most effective adjunctive interventions to maximise patient outcomes.

UNASSIGNED: To discuss treatment strategies for non-traumatic, non-iatrogenic hepatic artery aneurysms (HAAs) in the presence of an arteriobiliary fistula, illustrated by a case and followed by a comprehensive review of the literature.
UNASSIGNED: Following the PRISMA guidelines, 24 eligible HAA cases presenting with haemobilia were identified. Characteristics of patients, aneurysms, treatment strategies and their outcomes were collected.
UNASSIGNED: A 69 year old patient with no previous hepatobiliary intervention or trauma, presented with jaundice and haemobilia caused by a HAA. Initial treatment by endovascular stenting was chosen to prevent ischaemic liver complications. Unfortunately, this strategy failed because of stent migration due to ongoing infection leading to a type 1A endoleak. The patient had to be converted to open surgery with ligation of the HAA. The patient recovered uneventfully and no complications occurred during the following 12 months.
UNASSIGNED: Of the 24 cases, nine had a true HAA and 15 were pseudo/mycotic aneurysms, mainly caused by endocarditis or cholecystitis. The majority were located in the right hepatic artery. In 20 cases, an endovascular first approach was chosen with embolisation, none with covered stents. Three of these cases had to be converted to open surgery because of rebleeding. In all open (primary or secondary) cases, ligation of the HAA was performed. One patient in these series died. No liver ischaemia or abscesses were reported, although one patient developed an ischaemic gallbladder.
UNASSIGNED: Patients who present with a HAA and haemobilia may be treated safely by embolisation or open ligation. Using a covered stent graft in these patients can cause problems due to ongoing infection and should be monitored closely by imaging. Publication bias and lack of long term follow up imply cautious interpretation of these findings.

BACKGROUND: Surgical site infection (SSI) presents a ubiquitous concern to surgical specialties, especially in the presence of prosthetic material. Antibiotic-impregnated beads present a novel and evolving means to combat this condition. This review aims to analyze the quality of evidence and methods of antibiotic bead use, particularly for application within vascular surgery.
METHODS: A systematic scoping review was conducted within Embase, MEDLINE, and the Cochrane Registry of Randomized Controlled Trials. Articles were evaluated by 2 independent reviewers. Level of evidence was evaluated using the Oxford Center for Evidence-Based Medicine Criteria and the Cochrane Risk of Bias Tool for Randomized Controlled Trials.
RESULTS: The search yielded 6951 papers, with 275 included for final analysis. Publications increased in frequency from 1978 to the present. The most common formulation was polymethyl methacrylate; however publications on biodegradable formulations, including calcium sulfate beads, have been published with increasing frequency. Most publications had positive conclusions (94.2%); however, the data was mainly subjective and may be prone to publication bias. Only 11 randomized controlled trials were identified and all but one was evaluated to be at a high risk of bias. The most common indication was for osteomyelitis (52%), orthopedic prosthetic infections (20%), and trauma (9%). Within vascular surgery, beads have been used primarily for the treatment of graft infection, with freedom from recurrence rates being reported from 41% to 87.5%.
CONCLUSIONS: Antibiotic-impregnated beads provide a means to deliver high doses of antibiotic directly to a surgical site, without the risks of parenteral therapy. There has yet to be significant high-level quality data published on their use. There is a large body of evidence that suggests antibiotic beads may be used in SSIs in high-risk patients, prosthetic infections, and other complex surgical infections. Important potential areas of application in vascular surgery include graft infection, prevention of wound infection in high-risk patients, and diabetic foot infection.

Microsporidia are intracellular organisms most commonly known to cause opportunistic infection in patients with human immunodeficiency virus (HIV). There have been several case reports of infection in solid organ and bone marrow transplant recipients. Here, we report a case of a non-HIV-infected renal transplant patient with microsporidiosis of the renal tract associated with acute graft dysfunction. We also review the literature of 12 previously reported cases of microsporidiosis in patients with renal transplants who had described graft involvement. We review the pattern of illness as well as the common renal biopsy features when microsporidial infection is associated with renal graft infection.

The potent immunosuppressive drugs used by transplant recipients place them at risk of infections. Data on infective endocarditis (IE) in the setting of renal transplantation (RT) are sparse. We describe a 36-year-old woman referred to a tertiary medical center for evaluation of elevated creatinine levels 1 month after a second RT. Work-up revealed the presence of all four of Duke\'s criteria: fever, persistent bacteremia, new-onset tricuspid regurgitation, and masses suspected to be vegetation attached to the tricuspid annulus. Symptoms resolved with antibiotic treatment and fluids. Fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) revealed hypermetabolic absorption in the femoral vascular graft that had been used for hemodialysis prior to transplantation. The graft was removed by open surgery, and the patient was discharged home in good condition with continued antibiotic treatment. Review of the literature yielded 73 previously reported cases of IE in renal transplant recipients. Several differences were noted from IE in the general population: lower male predominance, younger age (<60 years), absence in most cases of a preexisting structural cardiac anomaly, and more variable causative pathogens. Our case also highlights the importance of FDG-PET/CT for detecting the source of IE and alerts clinicians to the sometimes unexpected course of the disease in renal transplant recipients.