Control of infection with prosthetic grafts: added value of Intergard Synergy

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The Intergard Synergy graft (from Maquet) is the first vascular prosthesis combining two well-known antimicrobial agents: silver acetate and triclosan. While silver acetate and triclosan are effective antimicrobial agents alone, their power to prevent development of infection is intensified when combined and offers increased antimicrobial properties. In vitro testing of the Intergard Synergy vascular graft demonstrates antimicrobial efficacy against a broad spectrum of micro-organisms including MRSA (methicillin-resistant Staphylococcus aureus).

The Intergard Synergy graft was featured in an edited live case presented at the Charing Cross Symposium (28 April–1 May, London, UK). The case was performed by Jean-Paul de Vries, head, Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, The Netherlands. The device was used to treat a 62-year-old female patient with a mycotic abdominal aorta.

The patient was referred to St Antonius Hospital in February 2015 with lower back pain, abdominal pain, fever and malaise. Laboratory tests showed anaemia, elevated leucocytes count and an elevated CRP of 264. Blood culture showed gram-positive cocci. The patient’s medical history included hypertension, hypercholesterolemia, a transient ischaemic attack in 2009, chronic obstructive pulmonary disease, a myocardial infarction and treatment with bypass graft in 2014 and Lerich syndrome in 2014 as well as severe claudication.

“CT scans showed inflammatory tissue around the aorta 1cm below the renal arteries and abscesses on the right side of the aorta. There was no aneurysm but a huge inflammatory mass and abscesses on the periaortic surroundings. We diagnosed the patient with mycotic abdominal aorta combined with Leriche syndrome with occlusion of both common and external iliac arteries,” De Vries explained. “The patient was already on intravenous antibiotics (Cefotaxime). She had severe stenosis of the superior mesenteric artery and coeliac trunk so before surgery we treated her with angioplasty and stenting of both visceral arteries.”

Surgery in a hybrid operating room was then performed with an in-situ reconstruction with an aorto-bifemoral Intergard Synergy, removal of the inflammatory tissue and wrapping of the graft with the greater omentum flap.

After performing a transabdominal incision, De Vries said, it was possible to see severe inflammation with approximately 250ml of pus between the bowel and the aorta.

“It took us some time to have a clear view of the juxta-renal aorta because of the severe adhesive tissue. We ligated the left renal vein to have a better overview of the area as we wanted to sew the Intergard Synergy graft just below the renal arteries,” he told delegates. “We could not identify the source of the infection so we did all kinds of investigation but we did not find it.”

The operator used a bifurcated Intergard Synergy with proximal diameter of 18mm and limbs of 9mm. De Vries explained that the graft is the only one to be loaded with two different antiseptics, adding that these antiseptics are “not limited to one target and do not have the likelihood to produce bacterial resistance”.

Subsequently the operators clamped the aorta at the diaphragm and opened the aorta at the infrarenal segment. “We performed proximal anastomosis in an inlay fashion and there was no severe bleeding after we declamped the suprarenal aorta. Clamping time was approximately 25 minutes. We had a cell saver in place but we did not have to use it,” he said.

After the team changed gloves, they then opened the patient’s groins to tunnel the aorto bifemoral graft. De Vries noted that on the right leg the patient had an occlusion in the superficial femoral artery, and an anastomosis of the profunda femoral artery was performed. On the left side, both the profunda and the superficial femoral artery were patent and an anastomosis was performed in the left common femoral artery. He commented: “We then performed the tunnelling of the Intergard Synergy graft and anastomosis, closed the groins using staplers and removed the great omentum to cover the graft, concluding the procedure.”

Bacteria culture showed the presence of Haemolytic streptococci group B and postoperatively the patient was put on eight weeks of intravenous penicillin with a PICC line in the brachial vein and enteral nutrition. She stayed in the surgical ward for 12 days. CT scan at two months showed good results with proximal and distal anastomosis. “We were happy that there was no microscopic inflammation around the Intergard Synergy,” De Vries said.

In conclusion, De Vries said, protocolised pre- and perioperative measures have to be taken into account to prevent surgical site infections. Surgical debridement and reconstruction is one of the key elements in the treatment of mycotic aortic disease. The unique silver/triclosan coated Intergard Synergy prevents bacterial colonisation during in-situ reconstructions.

In an in vitro experience comparing the Intergard Synergy vascular graft with a previous generation graft (Intergard Silver) against methicillin-resistant Staphylococcus aureus, Intergard Synergy showed faster antimicrobial efficacy and yielded significantly lower colony-forming units/mL counts already after four hours compared to the silver graft. The experience was reported in two papers authored by Jean-Baptiste Ricco et al (J Vasc Surg 2012;55(3):823–9) and by Ricco alongside Ojan Assadian (Semin Vasc Surg 24:234–241).

 

The Integard Synergy edited live case is available on the CX 2015 media library. Please visit www.cxsymposium.com for more information

 

This article has been sponsored by Maquet

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