Management of graft infections following abdominal aortic aneurysm replacement

Abstract

AbstractGraft infection following resection of an abdominal aortic aneurysm is a rare but highly lethal complication. It is most commonly associated with aortoenteric fistula or external contamination when graft limbs extend to the groin. Other sources are bowel or urinary tract entry, latent infection in the aneurysm wall, breaks in sterile technique, or bacteremia. Diagnosis should be suspected when a patient with an aortic graft develops unexplained fever, especially with back or abdominal pain, gastrointestinal bleeding of any kind, or metastatic infection to the limbs. Diagnosis is difficult to establish. Endoscopy to demonstrate erosion into the distal duodenum or to rule out other sources of bleeding was useful in all 6 patients in which it was employed. Positive arterial cultures distal to the graft, the finding of bilateral hydronephrosis, and demonstration of periaortic inflammation on gallium scan are highly suggestive. Aortography was helpful in 2 of 6 patients but was useless when negative. Barium contrast x‐ray studies were usually negative (90%) or confusing. Management requires excision of all infected graft material, usually the entire prosthesis. Restoration of limb circulation, usually with axillo femoral bypass, should be done in all patients except those with prior amputation or previous iliac artery or graft occlusion with adequate collaterals. A 35% patient survival rate was achieved in 20 patients with graft infection and aortoenteric fistula. However, when a correct diagnosis was made without delay and appropriate principles of management were instituted, 78% (7 of 9) patients survived and no amputations were required in the 5 patients with intact limbs. Prevention of postaneurysmectomy graft infection requires meticulous aseptic technique, effective graft coverage and separation from loops of bowel with viable tissue, and the use of prophylactic systemic and local antibiotics.