Treatment strategies and outcomes of endograft infections following endovascular abdominal aneurysm repair

Abstract

Objective To summarize the experience of diagnosis and treatment of stent infection after endovascular abdominal aneurysm repair (EVAR). Methods This retrospective analysis of post-EVAR stent infections was conducted at the First Affiliated Hospital, Sun Yat-sen University from January 2011 to June 2019, and the causes, clinical manifestations, reintervention and prognosis of infection were analyzed. Results Fifteen patients were identified, and all were male, with a median age of 65 years (range: 48~77 years). The median interval time between onset and EVAR was 7.5 months (range: 21 d~27 months). Aortoenteric fistula (AEF) was found in 6 patients (40%). Only 7 patients (47%) were positive of bacterial culture. Four (2 AEF, 2 non-AEF) received conservative treatment. Stent removal was performed in 11 patients (4 AEF, 7 non-AEF). Among them, 9 patients underwent axillary-bilateral femoral artery bypass, 2 patients underwent abdominal aorta reconstruction in situ and the patients with AEF underwent intestinal fistula repair at the same time. The 30-day early mortality was 33% (5/15), including 3 cases died in the perioperative period and the other 2 patients complicated with AEF died after conservative treatment. The median follow-up time of 10 survivors was 33 months (range: 6~54 months). Among them, 2 cases of infection recurred after conservative treatment with a middle and long-term death rate of 50% (1/2) and a recurrence rate of 100% (2/2). In 8 postperative patients, only one died of cerebrovascular accident two years later, whereas no recurrence of infection occurred. The middle and long-term death rate and the recurrence rate of postoperative patients was 13% (1/8) and 0% (0/8), respectively. In total, the overall mortality was 47% (7/15). The early mortality rate of patients with AEF was higher than that of non-AEF [67% (4/6) vs 11% (1/11), P=0.047], but there was no significant difference in the long-term mortality and infection recurrence rate [50%(1/2) vs 25% (2/8), P=0.38]. Conclusions Outcomes of stent infection after EVAR are poor, and AEF is common presentation that portend a significantly worse prognosis. Surgery is an effective treatment based on adequate anti-infective treatment. Key words: Endovascular abdominal aneurysm repair; Endograft infection; Aortoenteric fistula; Mortality; Axillary-bilateral femoral artery bypass; Reconstruction in situ