Treatment strategies and outcomes in patients with infected aortic endografts

Abstract

Endovascular abdominal (EVAR) and thoracic (TEVAR) endografts allow aneurysm repair in high-risk patients, but infectious complications may be devastating. We reviewed treatment and outcomes in patients with infected aortic endografts. Twenty-four patients were treated between January 1997 and July 2012. End points were mortality, morbidity, graft-related complications, or reinfection. Twenty males and four females with median age of 70 years (range, 35-80 years) had 21 infected EVARs and 3 TEVARs. Index repairs performed at our institution included eight EVARs and two TEVARs (10/1300; 0.77%). There were 19 primary endograft infections, 4 graft-enteric fistulae, and 1 aortobronchial fistula. Median time from repair to presentation was 11 months (range, 1-102 months); symptoms were fever in 17, abdominal pain in 11, and psoas abscess in 3. An organism was identified in 19 patients (8 mono- and 11 polymicrobial); most commonly Staphylococcus in 12 and Streptococcus in 6. All but one patient had successful endograft explantation. Abdominal aortic reconstruction was in situ repair in 21 (15 rifampin-soaked, 2 femoral vein, and 4 cryopreserved) and axillobifemoral bypass in three critically ill patients. Infected TEVARs were treated with rifampin-soaked grafts using hypothermic circulatory arrest. Early mortality (30 days or in-hospital) was 4% (n = 1). Morbidity occurred in 16 (67%) patients (10 renal, 5 wound-related, 3 pulmonary, and 1 had a cardiac event). Median hospital stay was 14 days (range, 6-78 days). One patient treated with in situ rifampin-soaked graft had a reinfection with fatal anastomotic blowout on day 44. At 14 months median follow-up (range, 1-82 months), patient survival, graft-related complications, and reinfection rates were 79%, 13%, and 4%, respectively. Endograft explantation and in situ reconstruction to treat infections can be performed safely. Extra-anatomic bypass may be used in high-risk patients. Resection of all infected aortic wall is recommended to prevent anastomotic breakdown. Despite high early morbidity, the risk of long-term graft-related complications and reinfections is low.