Search Results (25)

Background: Prosthetic vascular graft infection (PVGI) is a serious complication associated with vascular prostheses. Nuclear medicine techniques, including [¹⁸F]fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) and ^99mtechnetium-hexamethylpropylene amine oxime (HMPAO)-labeled leukocyte (WBC) scintigraphy, are part of the MAGIC diagnostic criteria for PVGI. Methods: In this retrospective study, we analyzed eight patients with suspected PVGI who underwent both [¹⁸F]FDG PET/CT and WBC scintigraphy within an average of 8 days. Results: Of all eight patients (median age 69 years), three showed concordant positive results with both PET/CT and WBC, and their final diagnosis confirmed the presence of infection; five showed discordant results: in all five of these patients, PET/CT showed false-positive findings, whereas WBC correctly identified five true-negative cases. Conclusions: [¹⁸F]FDG PET/CT is highly sensitive but prone to false positives. WBC scintigraphy, combined with SPECT/CT, particularly in the evaluation of the treatment response, showed greater specificity, and it may warrant consideration as a MAGIC major diagnostic criterion for PVGI. Full article

Background/Objectives: Peripheral prosthetic vascular graft infection represents a very serious complication after lower limb revascularization, with amputation and mortality rates up to 70% and 30%, respectively. This study was designed to determine the incidence of prosthetic graft infection, amputation, and mortality rate in our institution, analyzing different types of treatment. Methods: A retrospective cohort single institution review of peripheral prosthetic bypass grafts evaluated patient demographics, comorbidities, indications, location of bypass, type of prosthetic material, and case urgency and evaluated the incidence of graft infections, amputations, and mortality. Results: Between January 2016 and December 2021, a total of 516 bypasses were recorded (318 male, 198 female, mean age 74.2): 320 bypasses in venous material and 196 prosthetic bypasses using Dacron or PTFE. Among patients with a prosthetic bypass, 16 (8.2%) presented a graft infection at a mean follow-up of 39 months. Thirteen other patients who submitted to prosthetic peripheral bypass in other centers presented to our institution with a graft infection, so a total of 29 infected grafts were treated. Infected grafts were removed in 20 patients (68.9%), while a conservative treatment was helpful in nine cases (31.1%). The germs involved were Gram-negative in 27.6% and Gram-positive in 41.4%. During follow-up, we recorded five deaths (17.2%) and six amputations (20.7%) directly after bypass excision; another two amputations (6.9%) occurred after failure of the new bypass replacing the prosthesis removed. Conclusions: Redo-bypass, active infection at the time of bypass, and advanced gangrene were associated with a higher risk for prosthetic graft infection and major extremity amputation. Complete graft removal and replacement by venous material or Omniflow II represents the typical treatment. However, aggressive local treatment including drainage, debridement, vacuum-assisted closure therapy application, and muscle transposition seem to be a better solution in selected patients without the need for graft removal and with rates of limb salvage superior to those obtained with excisional therapy. Full article

The development of prosthetic limbs has benefited individuals who suffered amputations due to accidents or medical conditions. During the development of conventional prosthetics, several challenges have been observed regarding the functional limitations, the restricted degrees of freedom compared to an actual human limb, and the biocompatibility issues between the surface of the prosthetic limb and the human tissue or skin. These issues could result in mobility impairments due to failed mimicry of the actual stress distribution, causing discomfort, chronic pain, and tissue damage or possible infections. Especially in cases where underlying conditions exist, such as diabetes, possible trauma, or vascular disease, a failed adaptation of the prosthetic limb could lead to complete abandonment of the prosthetic part. To address these challenges, the insertion of topologically optimized parts with a biomimetic approach has allowed the optimization of the mimicry of the complex functionality behavior of the natural body parts, allowing the development of lightweight efficient anthropomorphic structures. This approach results in unified stress distribution, minimizing the practical limitations while also adding an aesthetic that aids in reducing any possible symptoms related to social anxiety and impaired social functioning. In this paper, the development of a novel anthropomorphic designed prosthetic foot with a novel Thermoplastic Polyurethane-based composite (TPU-Ground Tire Rubber 10 wt.%) was studied. The final designs contain advanced sustainable polymeric materials, gyroid lattice geometries, and Finite Element Analysis (FEA) for performance optimization. Initially, a static evaluation was conducted to replicate the phenomena at the standing process of a conventional replicated above-knee prosthetic. Furthermore, dynamic testing was conducted to assess the mechanical responses to high-intensity exercises (e.g., sprinting, jumping). The evaluation of the dynamic mechanical response of the prosthetic limb was compared to actual plantogram-derived foot pressure data during static phases (standing, light walking) and dynamic phenomena (sprinting, jumping) to address the optimal geometry and density, ensuring maximum compatibility. This innovative approach allows the development of tailored prosthetic limbs with optimal replication of the human motion patterns, resulting in improved patient outcomes and higher success rates. The proposed design presented hysteretic damping factor and energy absorption efficiency adequate for load handling of intense exercises (0.18 loss factor, 57% energy absorption efficiency) meaning that it is suitable for further research and possible upcycling. Full article

Background/Objectives: Vascular graft infections (VGIs) represent a life-threatening complication, occurring in 0.2–6% of patients following aortic prosthetic placements. Historically, the primary focus for reducing VGIs has been on prevention. Currently, antimicrobial grafts are not available on the market. This study aimed to evaluate the efficacy of combining two antibiotics, fosfomycin and oritavancin, impregnated into the commercially available Gelweave^TM vascular graft as a prophylactic alternative against the most commonly implicated bacteria responsible for VGI. Methods: The antimicrobial activity of fosfomycin and oritavancin was assessed using the broth microdilution method, and a synergistic effect was demonstrated using the checkerboard assay against Staphylococcus epidermidis, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant Enterococcus faecium. The antibiotics were impregnated into the commercial vascular graft through immersion, and the antimicrobial efficacy of the fosfomycin/oritavancin-impregnated graft was assessed over a period of 7 days. Results: Eradication of all microorganisms tested was achieved using impregnation solutions with concentrations of 40 mg/mL of fosfomycin and 256 µg/mL of oritavancin. Conclusions: Impregnation with the combination of fosfomycin/oritavancin proved to be a promising approach to prevent VGIs. Vascular grafts with impregnated antibiotics are not yet available on the market, and this work represents an important step toward the development of a new class of antimicrobial vascular grafts. Full article

Background: The reconstruction of large breasts carries a heightened risk profile. While skin-reducing mastectomy (SRM) techniques facilitate the correction of breast ptosis, they are frequently associated with a high incidence of vascular complications. This study compares two SRM techniques—the horizontal incision and the classic inverted T incision—by examining their clinical and surgical outcomes. Methods: We retrospectively analyzed data from 24 patients (30 breasts) who underwent SRM with immediate prosthetic reconstruction between 2019 and 2023 at the European Institute of Oncology in Milan, Italy. Our comparison focused on breast aesthetic outcome, reconstruction quality, complication rates (early and late), and patient satisfaction, utilizing the BREAST-Q questionnaire to gauge the latter. Results: Among the 24 patients included in the study, 16 (20 breasts) were treated with the inverted T technique, and 8 (10 breasts) with the horizontal incision approach. A higher overall complication rate was observed with the inverted T technique compared to the horizontal method, with early complications outnumbering late ones. The most common issues were recurrent seroma and skin necrosis leading to implant exposure. Notably, there were no cases of implant infection. Although the horizontal incision technique achieved slightly higher patient satisfaction scores, the difference was not statistically significant. Discussion: The inverted T and horizontal incision techniques each have unique benefits and drawbacks. Our findings indicate enhanced patient satisfaction and reduced complication rates with the horizontal incision technique. The selection of the technique should be customized based on the patient’s individual risk factors, tissue quality, and preferences. Full article

Mycobacterium chimaera (MC), a member of the Mycobacterium avium complex, can cause infections in patients after open-heart surgery due to contaminated heater–cooler units (HCUs). The transmission route of HCU-related MC infection is non-inhalational, and infection can occur in patients without previously known immune deficiency. Patients may develop endocarditis of the prosthetic valve, infection of the vascular graft, and/or manifestations of disseminated mycobacterial infection (splenomegaly, arthritis, hepatitis, nephritis, myocarditis, etc.). MC infections have serious outcomes (30–50% recurrence rate, 20–67% mortality rate). In 2015, an international outbreak of M. chimaera infections among patients undergoing cardiothoracic surgeries was associated with exposure to contaminated LivaNova 3T HCUs (formerly Stöckert 3T heater–cooler system, London, United Kingdom). In response to the global outbreak, many international agencies have issued directives and recommendations in order to reduce the risk of MC infection in cardiac surgery. Whole-genome sequencing (WGS) technology can be used to describe the global spread and dynamics of MC infections, to characterize local outbreaks, and also to identify sources of infection in hospital settings. In order to minimize the risk of contamination of HCUs and reduce the risk of patient infection, it is imperative that healthcare facilities establish a program of regular cleaning and disinfection maintenance procedures as well as monitoring of the water used and the air in the operating room, in accordance with the manufacturer’s procedure. Full article

Background: Biologic graft infection (BGI) is one of the main complications in graft reconstructions. However, very little evidence exists regarding the epidemiology of BGI, as most of the data come from sparse reports. Moreover, most of the series did not detail the treatment and outcome of graft infections. The aim of this systematic review of the literature is to provide a comprehensive data collection on BGI after oncologic resections. Methods: Three different databases (PubMed, Scopus, and Web of Science) were searched for relevant articles, and further references were obtained by cross-referencing. Results: 139 studies met the inclusion criteria. A total of 9824 grafts were retrieved. Among these, 684 (6.9%) were in the humerus, 365 (3.7%) in the pelvis, 2041 (20.7%) in the femur and 1660 (16.8%) in the tibia. Most grafts were osteoarticular (2481, 26.7%) and intercalary 2112 (22.7%) allografts. In 461 (5.0%), vascularized fibula grafts (VFGs) were used in combination with recycled autografts. Recycled grafts were reported in 1573 (16.9%) of the cases, and allograft-prosthetic composites in 1673 (18.0%). The pelvis and the tibia had the highest incidence of BGI (20.4% and 11.0%, respectively). The most reported first treatment was debridement and implant retention (DAIR) in 187 (42.8%) cases and two-stage revision with graft removal in 152 (34.8%). Very little data are reported on the final outcome specified by site or type of graft. Conclusions: This systematic review of the literature confirms a high incidence of infections in biologic reconstructions after resections of primary bone tumors. Despite DAIR being a viable attempt, in most cases, a two-stage approach with graft removal and reconstruction with endoprosthesis presented the highest chance to overcome infection, guaranteeing a reconstruction. We emphasize the need for future multicentric studies to focus on the management of infections after biological reconstructions in bone sarcomas. Full article

Infective endocarditis (IE) is a disease that may cause significant morbidity and mortality. IE is classically caused by Gram-positive microorganisms; however, Gram-negative bacteria may seldom also be the cause. Campylobacter species cause zoonosis and may also infect humans, mainly causing gastrointestinal infection by C. jejuni or invasive disease by C. fetus, such as bacteremia, sepsis, meningitis, or vascular infection. Campylobacter species IE has rarely been described, and most reports are cases and/or case series. Thus, the characteristics of this disease, including its epidemiology, clinical presentation, treatment, and outcome, remain largely unknown. This study aimed to review all published Campylobacter IE cases and describe their characteristics. A thorough search of PubMed, the Cochrane Library, and Scopus for published studies providing information on epidemiology, clinical findings, treatment, and outcome of Campylobacter IE cases was performed for the present narrative review. A total of 22 studies containing data from 26 patients were located and included. Among all patients, 73.1% were male; the median age was 65 years. Among all patients, 36.4% had a history of a prosthetic valve. The most commonly affected valve was the aortic, followed by the mitral. Fever, heart failure, and sepsis were the most frequent clinical findings. The most commonly isolated pathogen was C. fetus, with only one patient having C. jejuni IE. Antimicrobial resistance was low for all antimicrobials, with tetracycline having the highest resistance. Aminoglycosides and beta-lactams were the most commonly used antimicrobials. Surgery was performed in 48% of patients. The mortality rate was 26.9%. Patients who died were more likely to have sepsis, shock, and heart failure and were less likely to have been treated with aminopenicillins; however, no factor was identified in a multivariate logistic regression model as an independent factor for overall mortality. Full article

Background: Post-radiation fractures are a significant complication of cancer treatment, often being challenging to manage and impacting patients’ quality of life. This study systematically reviews the literature on fractures in irradiated bones, focusing on risk factors, treatment modalities, and prevention strategies. Factors increasing fracture risk include exposure to high doses of radiation of at least 50 Gy, female gender, menopausal age, and periosteal stripping. Additionally further risk factors are the size of the original tumor and osteoporosis. Methods: A search of PubMed yielded 541 articles, with 4 were ultimately included in the review. These retrospective studies focused on patients undergoing Combined Limb-Sparing Surgery and Radiation Therapy for soft tissue sarcoma. Results: Results show post-radiation fractures affect approximately 4% of patients, with the femur being the most frequently affected site. Intramedullary nailing emerges as the gold standard treatment, with prosthetic replacement or megaprostheses used in the metaepiphyseal region and as salvage procedures. Non-union and infection remain formidable complications. Conclusions: This study highlights the importance of prophylactic nailing in fracture prevention and the efficacy of free vascularized fibular flaps to achieve bone union during revision surgeries. Limited case availability and patient follow-up hinder comprehensive studies, impacting treatment outcomes. Full article

Prosthetic infections are associated with high morbidity, mortality, and relapse rates, making them still a serious problem for implantology. Staphylococcus aureus is one of the most common bacterial pathogens causing prosthetic infections. In response to the increasing rate of bacterial resistance to commonly used antibiotics, this work proposes a method for combating pathogenic microorganisms by modifying the surfaces of synthetic polymeric biomaterials using proteolytic enzyme inhibitors (serine protease inhibitors—4-(2-aminoethyl)benzenesulfonyl fluoride hydrochloride and puromycin). While using techniques based on the immobilization of biologically active molecules, it is important to monitor the changes occurring on the surface of the modified biomaterial, where spectroscopic techniques (e.g., FTIR) are ideal. ATR-FTIR measurements demonstrated that the immobilization of both inhibitors caused large structural changes on the surface of the tested vascular prostheses (polyester or polytetrafluoroethylene) and showed that they were covalently bonded to the surfaces of the biomaterials. Next, the bactericidal and antibiofilm activities of the tested serine protease inhibitors were determined using the CLSM microscopic technique with fluorescent staining. During LIVE/DEAD analyses, a significant decrease in the formation of Staphylococcus aureus biofilm after exposure to selected concentrations of native inhibitors (0.02–0.06 mg/mL for puromycin and 0.2–1 mg/mL for 4-(2-aminoethyl)benzenesulfonyl fluoride hydrochloride) was demonstrated. Full article

Background: Actinomycosis represents a challenging and under-reported complication of vascular surgery. Optimal management of Actinomyces spp. prosthetic vascular graft infection (PVGI) is highly uncertain because of the paucity of reports on this disease. Methods: We conducted a retrospective case-series of Actinomyces-PVGI that occurred in the last five years in two major university hospitals in northern Italy. We searched for previously published cases in the scientific literature. Results: We report five original cases of Actinomyces spp. prosthetic vascular graft infection following aortic aneurysm repair. Our literature review retrieved eight similar cases. Most patients were immunocompetent males. Most infections were polymicrobial (11/13 cases), with a prevalence of A. odontolyticus involvement (3/13 cases were associated with. Salmonella spp. infection). All cases had a late presentation (≥4 months from graft placement), with 61% associated with an aorto-enteric fistula. All patients received antibiotic therapy, but the duration was highly heterogeneous (from two weeks to life-long antibiotics). The patients without surgical revision experienced septic recurrences (2/13), permanent dysfunction (1/13), or a fatal outcome (2/13), while of the remainder who underwent vascular graft explant, six recovered completely and one developed a periprosthetic abscess. In two cases follow-up was not available. Conclusions: This case-series aims to raise the diagnostic suspicion and to describe the current management of Actinomyces-PVGIs. We highlight a high heterogeneity in antibiotic duration, choice of the antibiotic regimen, and surgical management. Higher reporting rate is advisable to produce better evidence and optimize management of this rare complication of vascular surgery. Full article

Dalbavancin represents a promising treatment for cardiovascular prosthetic infections due to its prolonged half-life, bactericidal activity, large spectrum of activity, and excellent biofilm penetration. However, the use of dalbavancin in this setting is limited, and only a few cases have performed therapeutic drug monitoring (TDM) analysis to optimize dosage in suppressive treatments longer than 4 weeks. Our retrospective case series reports the use of dalbavancin in a small cohort of patients with cardiovascular prosthetic infections (cardiac implantable electronic device infections (CEDIs), prosthetic valve endocarditis (PVE), prosthetic vascular graft infections (PVGIs)) treated with dalbavancin as sequential therapy. From May 2019 to May 2023, 14 patients were included: eight cases of PVE (57.1%), seven cases of PVGI (50%), three cases of CEDI (21.4%), and four cases with overlap of infection sites (28.6%). The main pathogen was Staphylococcus aureus (35.7%). Prosthesis replacement was obtained in four patients (28.6%). The median time between symptom onset and the end of treatment was 15 weeks (IQR 7–53), with a median duration of dalbavancin therapy of 8 weeks (IQR 1 to 45 weeks) and 3.5 doses per patient. Among patients managed with TDM-guided strategy, dalbavancin infusion intervals ranged from 4 to 9 weeks. The median length of follow-up was 65 weeks (IQR 23 to 144 weeks). Clinical success was achieved in 10 cases (76.9%); all clinical failures occurred in patients with the implant retained. Among patients monitored by TDM, clinical success was 87.5% vs. 60% in patients treated without TDM. Because of pharmacokinetic individual variability, dalbavancin TDM-guided administration could improve clinical outcomes by individualizing dosing and selecting dosing intervals. This case series seems to suggest a promising role of long-term suppressive dalbavancin treatment for difficult-to-treat cardiovascular prosthesis infection, also with limited surgical indications. Full article

Background: From 2013 onwards, a large outbreak of Mycobacterium chimaera (MC) invasive infection, which was correlated with the use of contaminated heater–cooler units (HCUs) during open chest surgery, was reported from all over the world. Here, we report the results of the epidemiological and molecular investigations conducted in Italy after the alarm raised about this epidemic event. Methods: MC strains isolated from patients or from HCU devices were characterized by genomic sequencing and molecular epidemiological analysis. Results: Through retrospective epidemiological analysis conducted between January 2010 and December 2022, 40 possible cases of patients infected with MC were identified. Thirty-six strains isolated from these patients were analysed by whole genome sequencing (WGS) and were found to belong to the genotypes 1.1 or 1.8, which are the genotypes correlated with the outbreak. Most of the cases presented with prosthetic valve endocarditis, vascular graft infection or disseminated infection. Among the cases found, there were 21 deaths. The same analysis was carried out on HCU devices. A total of 251 HCUs were found to be contaminated by MC; genotypes 1.1 or 1.8 were identified in 28 of those HCUs. Conclusions: To ensure patients’ safety and adequate follow-up, clinicians and general practitioners were made aware of the results and public health measures, and recommendations were issued to prevent further cases in the healthcare settings. The Italian Society of Cardiac Surgery performed a national survey to assess the incidence of HCU-related MC prosthetic infections in cardiac surgery. No cases were reported after HCU replacement or structural modification and disinfection and possibly safe allocation outside surgical rooms. Full article

Cardiovascular infections are the most severe and potentially lethal among the persistent focalized Coxiella burnetii infections. While aortic infections on aneurysms or prostheses are well-known, with specific complications (risk of fatal rupture), new non-aortic vascular infections are increasingly being described thanks to the emerging use of 18-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET-scan). Here, we describe an infection of a femoro-popliteal bypass that would not have been diagnosed without the use of PET-scan. It is well-known that vascular prosthetic material is a site favorable for bacterial persistence, but the description of unusual anatomical sites, outside the heart or aorta, should raise the clinicians’ awareness and generalize the indications for PET-scan, with careful inclusion of the upper and lower limbs (not included in PET-scan for cancer), particularly in the presence of vascular prostheses. Future studies will be needed to precisely determine their optimal management. Full article

Background. Minimally invasive surgery via right mini-thoracotomy has become the standard of care for the treatment of mitral valve disease worldwide, particularly at high-volume centers. In recent years, the spectrum of indications has progressively shifted and extended to fragile and higher-risk patients, also addressing more complex mitral valve disease and ultimately including patients with native or prosthetic infective endocarditis. The rationale for the adoption of the minimally invasive approach is to minimize surgical trauma, promote an earlier postoperative recovery, and reduce the incidence of surgical wound infection and other nosocomial infections. The aim of this retrospective observational study is to evaluate the effectiveness and the early and late outcome in patients undergoing minimally invasive surgery for mitral valve infective endocarditis. Methods. Prospectively collected data regarding minimally invasive surgery in patients with mitral valve infective endocarditis were entered into a dedicated database for the period between January 2007 and December 2022 and retrospectively analyzed. All comers during the study period underwent a preoperative evaluation based on their clinical history and anatomy for the allocation to the most appropriate surgical strategy. The selection of the mini-thoracotomy approach was primarily driven by a thorough transthoracic and especially transesophageal echocardiographic evaluation, coupled with total body and vascular imaging. Results. During the study period, 92 patients underwent right mini-thoracotomy to treat native (80/92, 87%) or prosthetic (12/92, 13%) mitral valve endocarditis at our institution, representing 5% of the patients undergoing minimally invasive mitral surgery. Twenty-six (28%) patients had undergone previous cardiac operations, whereas 18 (20%) presented preoperatively with complications related to endocarditis, most commonly systemic embolization. Sixty-nine and twenty-three patients, respectively, underwent early surgery (75%) or were operated on after the completion of the targeted antibiotic treatment (25%). A conservative procedure was feasible in 16/80 (20%) patients with native valve endocarditis. Conversion to standard sternotomy was necessary in a single case (1.1%). No cases of intraoperative iatrogenic aortic dissection were reported. Four patients died perioperatively, accounting for a thirty-day mortality of 4.4%. The causes of death were refractory heart or multiorgan failure and/or septic shock. A new onset stroke was observed postoperatively in one case (1.1%). Overall actuarial survival rate at 1 and 5 years after operation was 90.8% and 80.4%, whereas freedom from mitral valve reoperation at 1 and 5 years was 96.3% and 93.2%, respectively. Conclusions. This present study shows good early and long-term results in higher-risk patients undergoing minimally invasive surgery for mitral valve infective endocarditis. Total body, vascular, and echocardiographic screening represent the key points to select the optimal approach and allow for the extension of indications for minimally invasive surgery to sicker patients, including active endocarditis and sepsis. Full article