INTRODUCTION

Abdominal aortic prosthetic graft and endograft infections are an uncommon yet severe condition that can result in substantial morbidity and mortality if not properly addressed. These infections include native mycotic aneurysms, infected synthetic grafts, and endograft infections and represent one of the most challenging entities in vascular surgery. They originate from diverse sources, including hematogenous dissemination, adjacent infections, or iatrogenic factors.1 Despite being relatively uncommon, with an estimated incidence of 0.5-5% after open or endovascular aortic repair, these conditions are associated with significant morbidity and mortality due to sepsis, rupture, and fistula formation.2 Management is further complicated by diagnostic difficulties, the need for surgical debridement, and the limited availability of options for in-situ reconstruction.

Historically, treatment has relied on extra-anatomic bypass, cryopreserved arterial allografts, or autologous vein reconstruction. Extra-anatomic reconstructions, however, are associated with poor long-term patency and high reinfection rates. Autologous vein grafts (NAIS procedure) can provide durable results but are technically demanding, associated with significant donor site morbidity, and are often unsuitable in emergencies.2 Cryopreserved allografts are considered an excellent biological option, but their availability is limited, and they may undergo structural degeneration over time.3 Bovine pericardium has emerged as a promising biological material for in-situ reconstruction in infected sites. Its advantages include wide availability, biocompatibility, resistance to infection, and the ability to be tailored into self-made tube or bifurcated grafts. Since the first descriptions of custom-made xenopericardial tubes,4 a growing amount of research has shown positive results in various regions of the aorta. Initial studies conducted at single centers showed that the approach was feasible and resulted in low rates of reinfection.5, 6, 7 Subsequent larger studies across multiple centers have validated the mid-term durability of these findings. The European multicenter study by Weiss et al., including 168 patients, reported a 30-day mortality of 15% and a reinfection rate of only 6% at a median 26-month follow-up, with no cases of graft degeneration.8 Similarly, systematic reviews and meta-analyses have highlighted the consistently low reinfection rates (≈1-6%) and high patency (≈95-99%) associated with bovine pericardium reconstructions.9, 10, 11

Both self-made and prefabricated bovine pericardium grafts have been studied. Self-made xenopericardial tubes can be fabricated on-table into straight or bifurcated grafts, allowing customization to patient’s anatomy.7, 11 Prefabricated bovine pericardial grafts, such as the BioIntegral conduit, have also shown favorable outcomes in multicenter cohorts, with reinfection rates around 5-9% and patency exceeding 85% at mid-term follow-up.12, 13, 14 In various studies, the primary late complications are either an anastomotic pseudoaneurysm or stenosis occurring at the central or peripheral anastomosis.8, 4

The role of bovine pericardium grafts has now been recognized in international guidelines, with the 2020 ESVS Clinical Practice Guidelines on graft infections recommending xenopericardial grafts as a valid alternative when allografts or autologous vein are not available.2 Nevertheless, most published data are collected from heterogeneous, multicenter, or mixed pathology cohorts, and long-term (>5 – 10 year) durability remains insufficiently characterized.

Given these considerations, reporting additional single-center experiences is essential to refine the evidence base. In this study, we present our institutional results using self-made bovine pericardial grafts for the treatment of aortic infections, focusing on technical feasibility, early and mid-term outcomes, and comparison with published literature.

METHODS

This retrospective single-center cohort study included all patients who underwent in-situ aortic reconstruction with self-made bovine pericardium grafts for the treatment of synthetic or endografts infections and mycotic aortic infections in our Department between January 2019 and December 2024. The study was conducted in accordance with institutional ethical standards, and informed consent was obtained from all patients or their legal representatives.

All patients had clinical or radiologic evidence of infection as defined by the Management of Aortic Graft Infection Collaboration (MAGIC) criteria.15 Computed tomography imaging demonstrated inflammatory changes in all cases, and five patients (31.3%) presented with aortoenteric fistulae.

Preoperative microbiological assessment included blood cultures, wound swabs, and analysis of the explanted grafts when this was feasible. Empirical broad-spectrum intravenous antibiotics were started at the time of the diagnosis and subsequently tailored to culture results in collaboration with Infectious Disease Department.

All surgical procedures were performed through midline laparotomy or retroperitoneal exposure, depending on the site of infection. Radical debridement of all infected and necrotic tissue was performed in every case, followed by in-situ reconstruction with a self-made bovine pericardium graft. The grafts were fabricated intraoperatively from commercially available bovine pericardial patches. In cases involving the aortic bifurcation, bifurcated grafts were constructed in a similar fashion (Fig. 1). Omental wrapping of the reconstruction site was performed whenever technically feasible. The simultaneous surgical management for aortoenteric fistulae was conducted in collaboration with gastrointestinal surgeons.

Postoperatively, all patients were transferred to the Intensive Care Unit (ICU) for hemodynamic monitoring and continued intravenous antibiotic therapy. Antibiotics were administered for a minimum of six weeks and prolonged antibiotic therapy was prescribed in selected high-risk patients. Patients were followed at one, three, six, and twelve months after discharge, and annually thereafter. Follow-up included clinical examination, laboratory evaluation of inflammatory markers, and, if needed, computed tomography angiography to assess graft integrity, patency, and possible recurrence of infection.

Clinical data were retrieved retrospectively from hospital records, including demographic variables, microbiological results, operation details, and postoperative outcomes. Statistical analysis was performed using Jamovi 2.6 version. The primary endpoints of the study were in-hospital mortality, 30-day mortality and overall mortality. Secondary endpoints included perioperative complications, re-intervention rates, graft patency, and recurrence of infection.

RESULTS

Between 2019 and 2024, a total of 16 patients underwent in-situ aortic reconstruction using self-made bovine pericardium grafts at our center (Fig 2, 3). The cohort was predominantly male (87.5%), with a mean age of 66.6 years (range, 25-87 years). Indications for surgery included mycotic aneurysm in four patients (25%), infection of a prior endovascular aortic repair (EVAR/TEVAR) in four patients (25%), and infection of a conventional prosthetic graft in eight patients (50%).

All patients presented with clinical symptoms at diagnosis, including fever in 9 patients (56%), abdominal pain in 3 (19%), purulent discharge from a femoral-inguinal fistula in 2 (12.5%), pseudoaneurysm of the femoral anastomosis in 2 (12.5%) and gastrointestinal bleeding in 2 patients (12.5%). Computed tomography imaging demonstrated inflammatory lesions in every case, namely perigraft gas or fluid. Five patients (31.3%) had an associated aortoenteric fistula. Microbiological cultures were positive in 13 patients (81.3%), most frequently from explanted grafts (62.5%), followed by wound cultures (12.5%) and blood cultures (6.3%). Three patients (18.8%) had negative cultures. The mean duration of the preoperative antibiotic therapy was 7.1 ± 6.6 days.

The mean ICU stay was 2.6 days (range, 0-19 days), and the mean postoperative hospital stay was 11.9 days (range, 0-45 days). The 30-day death rate was 31.3% (5 patients), while in-hospital mortality was 37.5% (6 patients). The most common cause of death was graft disruption in 4 patients, followed by multiorgan failure due to sepsis in 2.

No patient died after hospital discharge, during a median follow-up of 8.3 months (range, 0-43 months), and no cases of infection recurrence were documented. One patient developed a pseudoaneurysm of the proximal anastomosis (Fig 4) 6 months after the bovine graft implantation, which was treated by endovascular repair with an aortic cuff. Another patient suffered from thrombosis of the right limb of an aortobifemoral bovine graft (Fig 5) 2 years after its implantation, which was treated with a femoro-femoral crossover graft.

DISCUSSION

In this retrospective single-center study, we evaluated the outcomes of 16 patients treated with self-made bovine pericardium graft for aortic infections. Our series demonstrates a 30-day mortality of 31.3% and an overall mortality of 37.5%. Despite the high perioperative risk associated with the severity of the disease in this cohort, we observed no cases of reinfection at a median follow-up of 8.3 months. Additionally, graft durability was favorable, with only one case of limb thrombosis and one case of proximal anastomotic pseudoaneurysm. These results align with, and further support, the growing evidence that bovine pericardium grafts are a viable option for in-situ reconstruction in infected aortic cases.

Comparison with existing evidence

Multiple single-center studies have reported favorable outcomes with self-made xenopericardial tubes. In the early feasibility series by Lutz et al., infection control was achieved in 75%, with 100% graft patency at 9 months, although two late ruptures occurred due to reinfection.6 Alonso et al. documented a 30-day mortality of 4.7% and 95% primary patency, with no recurrency of infection during a median follow-up of 14 months.7 Similarly, Czerny and colleagues reported in-hospital mortality of 16%, excellent mid-term patency, and freedom from reinfection in 98% of cases, though fungal infections were associated with poor outcomes.16 Zientara et al. highlighted the technical feasibility of self-made bovine pericardium grafts, showing 100% patency and no reinfections in their pericardium subgroup, with lower complication rates than allograft reconstructions.5

Our results compare favorably with these smaller series, particularly in terms of infection resistance, where we observed zero reinfections despite one-third of our patients (31.3%) presenting with aortoenteric fistulae. However, our early mortality was higher, which likely reflects the prolonged age and comorbidities in our population, including octogenarians and patients with septic clinical presentation. These results align with the study by Weiss et al., which is the most extensive multicenter cohort involving 168 patients. They observed a 30-day mortality rate of 15%, with higher rates in cases of graft infection compared to native infection and reported an 86% rate of freedom from reinfection over a period of 5 years.8 Significantly, throughout that series, no inherent deterioration of bovine pericardium grafts was observed, supporting the mid-term durability observed in our study.

Other mid-sized cohorts support these observations. Kreibich et al. reported acceptable outcomes using xenopericardial grafts for infectious aortic disease across various segments, emphasizing the technical versatility of the material.16 In a systematic review by Hostalrich et al., involving 71 patients, the mortality rate within 30 days was 25%. Additionally, 5.7% of the patients experienced reinfection, and 9% required further intervention, with no instances of graft thrombosis reported.9 Likewise, Grills et al. combined data from nine studies involving 133 patients and found that reinfection rates were extremely low (less than 1%) and patency was very high (over 95%). However, the overall mortality rate remained elevated at approximately 40% due to the underlying disease.10 A broader meta-analysis in the HJVES by Theodosopoulos et al., including 290 patients, confirmed these findings, with reinfection-free survival of 98.6% and primary patency of 99%.11 The collective data highlight the infection resistance and durability of bovine pericardium grafts, emphasizing that patient frailty and the severity of sepsis are the primary factors influencing overall outcomes.

Prefabricated bovine pericardial grafts

Alongside physician-made conduits, prefabricated bovine pericardium grafts have emerged as an attractive “off-the-shelf” option. The VASC-REGAIN study demonstrated a 1-year reinfection rate of 9%, occlusion in 6% of the cases, and procedure-related mortality of 16%.12 A preliminary experience with prefabricated grafts for aorto-iliac and infrainguinal reconstructions reported 30-day mortality of 17% for aorto-iliac and 8% for infrainguinal reconstructions, with reinfection-free survival of 94% and acceptable patency.17 Further mid-term analysis showed primary patency of 85% at 1 year and assisted primary patency rate of 96.3%.13 In a retrospective analysis conducted by Donato et al., which involved 20 patients, the in-hospital mortality rate was as low as 5%. Additionally, the primary patency was reported at 95%, and the re-infection rate was 5%.14 Our findings with self-fabricated grafts demonstrated comparable robustness in infection resistance, indicating that both approaches are effective. However, prefabricated grafts offer logistical advantages when rapid intervention is required, particularly in scenarios necessitating rapid intervention.

Comparison with alternative strategies

Autologous femoral vein reconstruction (NAIS) is considered highly resistant to infection but is technically demanding, time-consuming, and associated with donor-site morbidity, making it less feasible in urgent settings. Cryopreserved allografts remain an excellent biologic alternative, but supply is limited, and structural degeneration can occur. A French bicentric comparative study, involving 169 patients from 2010 to 2023, identified no significant differences in mid-term survival or reinfection-free survival between cryopreserved allografts and xenopericardial substitutes. This finding highlights the clinical efficacy equivalence of bovine pericardium grafts while emphasizing their advantage in terms of availability.3 Synthetic grafts treated with rifampicin or silver coatings have been used, but reinfection rates remain higher, particularly in cases with gross contamination or fistulation, as noted in the 2020 ESVS Guidelines.2

Limitations and clinical implications

Our study is limited by its retrospective design, small cohort size, and relatively short follow-up, which may underestimate late complications such as para-anastomotic pseudoaneurysm or primary or assisted primary patency —complications reported in other series.8, 4 Nevertheless, the absence of reinfections in our cohort, even in complex cases with aortoenteric fistulae, contributes additional evidence to the expanding collection of research that endorses the safety and efficacy of bovine pericardium grafts.

Taken together, the available evidence indicates that bovine pericardium, whether self-made or prefabricated, offers a robust, infection-resistant, and versatile solution for in-situ aortic reconstruction. While perioperative mortality remains significant, reflecting the critical illness of this patient population, graft-related outcomes are consistently favorable. Larger multicenter studies with long-term follow-up are required to confirm the durability of this approach and to better define its role relative to allografts and autologous vein grafts.

CONCLUSION

Our single-center experience demonstrates that self-made bovine pericardium grafts provide an effective and versatile option for in-situ reconstruction in patients with aortic infections. Despite an early mortality rate of 31.3%, indicative of the advanced age and comorbidity burden within our cohort, we observed no reinfections and excellent graft durability during follow-up. These results are in line with the largest European multicenter study, which reported a reinfection rate of only 6% at 5 years with no graft degeneration,8 and with other single-center series showing patency rates exceeding 90-95% and low recurrence of infection.7, 16, 6 Systematic reviews and meta-analyses further support these findings, consistently demonstrating very low reinfection rates (<6%) and high primary patency (~95-99%) across heterogeneous patient populations.9, 10, 11

Prefabricated bovine pericardial conduits have shown similar safety and efficacy, with reinfection rates of 5-9% and good mid-term patency.12, 13, 14 Compared with alternatives such as cryopreserved allografts, autologous femoral vein, or antibiotic-coated synthetic grafts, bovine pericardium offers the advantages of wide availability, on-table adaptability, and biocompatibility in contaminated fields, while achieving equivalent mid-term outcomes.2, 3

Taken together, the accumulated evidence establishes bovine pericardium – both self-made and prefabricated – as a durable biological conduit for aortic infection surgery. While perioperative mortality remains high, determined largely by patient frailty and clinical presentation, graft-related outcomes are consistently favorable. Larger multicenter studies with long-term follow-up are warranted, but current data, including our own, strongly support bovine pericardial grafts as a safe and effective alternative for the treatment of this complex and life-threatening condition.

References

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2. Chakfé N, Diener H, Lejay A, Assadian O, Berard X, Caillon J, et al. Editor’s Choice – European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Vascular Graft and Endograft Infections. Eur J Vasc Endovasc Surg Off J Eur Soc Vasc Surg. 2020 Mar;59(3):339-84.
3. Battistella L, Kireche R, Ricco JB, Boisroux T, Shourick J, Chaufour X, et al. Outcomes of native or graft abdominal aortic infection managed with orthotopic xeno pericardial grafts or cryopreserved allograft. J Vasc Surg. 2025 July 1;82(1):90-101.e3.
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5. Zientara A, Schwegler I, Dzemali O, Bruijnen H, Peters AS, Attigah N. Xenopericardial self-made tube grafts in infectious vascular reconstructions: Preliminary results of an easy and ready to use surgical approach. Vascular. 2016 Dec 1;24(6):621-7.
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12. Reinders Folmer EI, Verhofstad N, Zeebregts CJ, van Sambeek MRHM, Saleem BR, Willigendael EM, et al. Performance of the BioIntegral Bovine Pericardial Graft in Vascular Infections: VASCular No-REact Graft Against INfection Study. Ann Vasc Surg. 2023 Sept 1;95:116-24.
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14. Donato F, Donati T, Minelli F, Borghetti A, Minucci M, Luparelli A, et al. Treatment of Aorto-iliac and Infrainguinal Vascular Infections with a Prefabricated Bovine Pericardial Graft. Ann Vasc Surg. 2024 Aug 1;105:177-88.
15. Anagnostopoulos A, Mayer F, Ledergerber B, Bergadà-Pijuan J, Husmann L, Mestres CA, et al. Editor’s Choice – Validation of the Management of Aortic Graft Infection Collaboration (MAGIC) Criteria for the Diagnosis of Vascular Graft/Endograft Infection: Results from the Prospective Vascular Graft Cohort Study. Eur J Vasc Endovasc Surg Off J Eur Soc Vasc Surg. 2021 Aug;62(2):251-7.
16. Kreibich M, Siepe M, Berger T, Pingpoh C, Puiu P, Morlock J, et al. Treatment of infectious aortic disease with bovine pericardial tube grafts. Eur J Cardiothorac Surg. 2021 July 1;60(1):155-61.
17. Gregio A, Pini R, Faggioli G, Freyrie A, Tshomba Y, Pagliariccio G, et al. A Preliminary Experience on Prefabricated Bovine Pericardium Grafts for Aorto-iliac and Infrainguinal Reconstructions. J Vasc Surg. 2023 June 1;77(6):e220.