Introduction: Aortic graft and endograft infections (AGI) are rare, but a dreaded complication after aortic surgery. The frequency is difficult to assess due to varying definitions but has been reported to range from 0.3-4%. Only recently a proposal for a unanimous definition of AGI (the MAGIC-criteria) was published. As of now, three major surgical techniques are used to treat AGI; 1) a semiconservative (SC) approach with infection drainage and preservation of the vascular prosthesis, 2) resection of the infected vascular prosthesis with extra-anatomic bypass (EAB), or 3) in-situ repair (ISR) with a vein-, aortic allo-, or antibiotic soaked graft. The literature lacks comparative studies and mainly consists of small single center retrospective studies with a high degree of selection and publication bias. The aim of this study was to assess the outcome and risk factors of surgical treatment of AGI in a large nationwide cohort. Methods: Patients with an AGI-related surgery in a specific European country1 between 1995 and 2016 were identified using the nationwide registry for vascular surgeries1. The MAGIC-criteria were used as definition of an AGI. All vascular centers in the country were invited to participate in the study. A predetermined protocol for data extraction was designed and used for a retrospective case record review. Survival was compared between the three surgical groups at 30-days, 1-year and 5-years (Kaplan-Meier analysis). Predictors for long-term mortality were assessed with Cox-regression. Results: A total of 122 patients with a surgically managed AGI were identified with an additional estimate of 40-50 cases still under review2. The case mix consisted of 25 (20.5%) SC, 58 (37.5%) EAB and 39 (32.0%) ISR. A graft enteric fistula (GEF) was present in 61(50.0%). Within the ISR-group there were 21 vein-grafts, eight Silver-Dacron grafts, seven antibiotic-soaked grafts and three standard PTFE or Dacron grafts. Patients undergoing SC had a higher frequency of coronary heart disease and congestive heart failure (p< 0.05), there were no other differences in base-line comorbidities, age, frequency of emergency surgery or GEF between the groups. The median follow-up among survivors was 5.3 years. The estimated survival was; 30 day: SC 80.8% vs EAB 82.5% vs ISR 83.8% (p = ns), 1 year: SC 46.2% vs EAB 69.1% vs ISR 70.3% (p = ns), 5 years: SC 26.9% vs EAB 41.9% vs ISR 49.2% (p = ns). Survival after SC was significantly worse than EAB and ISR (pooled survival curve analysis EAB + ISR vs SC, p = 0.043). In a Cox-regression analysis including age, surgical technique, presence of GEF and clinical shock at presentation as covariables, only age had a significant correlation with overall survival (HR 1.08, p< 0.001). Conclusion: In a large non-selected nationwide AGI-cohort, mortality after surgical repair remains high. In contrast with some previous studies we could not identify any clear survival benefit using ISR vs EAB. Advanced age correlated with worse outcome. A semi-conservative approach was associated with a worse long-term outcome, at least partially explained by a more advanced comorbidity burden within this cohort. [Kaplain-Meier estimated overall survival comparing the three surgical groups.] Disclosure: Nothing to disclose
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