Outcomes of patients with aortic vascular graft and endograft infections initially contra-indicated for complete graft explantation.

Abstract

Complete excision in patients with aortic vascular graft and endograft infections (VGEIs) is a significant undertaking, and many patients never undergo definitive treatment. Knowing their fate is important to be able to assess the risks of graft excision vs alternative strategies. This study analyzed their life expectancy and sepsis-free survival. VGEIs were diagnosed according to the Aortic Graft Infection (MAGIC) criteria, and patients turned down for graft removal from November 2006 to December 2020 were included. Primary endpoints were aortic-related and sepsis-free survival estimated using the Kaplan-Meier method. A Cox proportional hazards regression analysis was used to compute the hazard ratio (HR) and 95% confidence interval (CI) as estimates of survival without sepsis. Seventy-four patients were included, with a median age of 71years (range, 63-79years). The index aortic repair was either open (n= 33; 44.6%), endovascular (n= 19; 25.7%), or hybrid (n= 22; 29.7%). Causative organisms were identified in 56 patients (75.7%). At presentation, 26 patients (35.1%) required salvage surgery, open (n= 22; 29.7%) or endovascular (n= 8; 10.8%), and 17 radiological drainage (23.0%). During follow-up, eight required drainage and 11 (14.9%) graft removal (five complete). Infectious complications included pseudoaneurysms (n= 14; 18.9%), rupture (n= 9; 12.2%), gastro-intestinal bleeding (n= 13; 17.6%), septic embolisms (n= 4; 5.4%), and thrombosis (n= 12; 16.2%). In-hospital mortality was 20.3% (n= 15), freedom from aortic-related death and overall survival was 77.1% (95% CI, 65.2%-85.3%) and 70.4% (95% CI, 58.3%-79.7%) at 1year, and 61.7% (95% CI, 46.1%-74.0%) and 43.1% (95% CI, 29.2%-56.3%) at 5years. Sepsis recurrence occurred in 37 patients (50.0%). Seven (16.3%) developed acquired antimicrobial resistance. Malnutrition (HR, 3.3; 95% CI, 1.4-7.6; P= .005), hemorrhagic shock at presentation (HR, 2.9; 95% CI, 1.0-8.2; P= .048), aorto-enteric fistulae (HR, 3.3; 95% CI, 1.3-8.4; P= .011), fungal coinfection (HR, 3.5; 95% CI, 1.2-11.5; P= .030), and infection with resistant micro-organisms (HR, 3.1; 95% CI, 1.1-8.3; P= .023) were significantly associated with worse survival without sepsis. In-hospital and aortic-related mortality were significant, but with salvage surgery and antibiotic therapy, the median survival was 3years. Sepsis recurrence remained frequent, and further procedures were needed. These outcomes should be considered when graft excision is proposed. Known predictors of adverse outcomes should become important points for discussion in multidisciplinary team meetings.