Management of Aortic Infections: Role of Open Surgery and the Value of Multidisciplinary Team Approach (original) (raw)
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Management of the infected aortic endograft
Seminars in Vascular Surgery, 2017
Although the incidence of abdominal and thoracic aortic endografts infection is infrequent, ranging between 0.2% and 5%, stent-graft infection carries significant morbidity and mortality and exemplifies a formidable therapeutic challenge. Treatment goal is to eradicate the infectious process by endograft explantation,, regional tissue debridement, and arterial reconstruction by either an extraanatomic or in situ grafting procedure using autologous vein, cryopreserved allograft, or antibioitcv soaked prosthetic grafts.. Successful treatment should maintain normal arterial perfusion to the visceral arteries and lower 2 extremities. Important treatment adjuncts included antibiotic therapy based on cultures specific bacterial isolates and , and coverage of the repair or aortic stump using an omental wrap. Nonoperative treatment in patients with severe comorbidities that precludes endograft explantation may be appropriate in the setting of low grade biofilm infection. Percutaneous drainage of the perigraft abscess followed by continuous antibacterial irrigation of the cavity can be utilized but is associated with a high clinical failure rate.
Treatment and outcomes of aortic endograft infection
Journal of vascular surgery, 2016
This study examined the medical and surgical management and outcomes of patients with aortic endograft infection after abdominal endovascular aortic repair (EVAR) or thoracic endovascular aortic repair (TEVAR). Patients diagnosed with infected aortic endografts after EVAR/TEVAR between January 1, 2004, and January 1, 2014, were reviewed using a standardized, multi-institutional database. Demographic, comorbidity, medical management, surgical, and outcomes data were included. An aortic endograft infection was diagnosed in 206 patients (EVAR, n = 180; TEVAR, n = 26) at a mean 22 months after implant. Clinical findings at presentation included pain (66%), fever/chills (66%), and aortic fistula (27%). Ultimately, 197 patients underwent surgical management after a mean of 153 days. In situ aortic replacement was performed in 186 patients (90%) using cryopreserved allograft in 54, neoaortoiliac system in 21, prosthetic in 111 (83% soaked in antibiotic), and 11 patients underwent axillary-...
A multicenter experience with infected abdominal aortic endograft explantation
Journal of Vascular Surgery, 2017
Objective: Endovascular aneurysm repair (EVAR) is widely used with excellent results, but its infectious complications can be devastating. In this paper, we report a multicenter experience with infected EVAR, symptoms, and options for explantation and their outcome. Methods: We have reviewed all consecutive endograft explants for infection at 11 French university centers following EVAR, defined as index EVAR, from 1998 to 2015. Diagnosis of infected aortic endograft was made on the basis of clinical findings, cultures, imaging studies, and intraoperative findings. Results: Thirty-three patients with an infected aortic endograft were identified. In this group, at index EVAR, six patients (18%) presented with a groin or psoas infection and six patients (18%) presented with a general infection, including catheter-related infection (n ¼ 3), prostatitis (n ¼ 1), cholecystitis (n ¼ 1), and pneumonia (n ¼ 1). After index EVAR, eight patients underwent successful inferior mesenteric artery embolization for a type II endoleak within 6 months of index EVAR and one patient received an additional stent for a type Ib endoleak 1 week after index EVAR. Median time between the first clinical signs of infection and endograft explantation was 30 days (range, 1 day to 2.2 years). The most common presenting characteristics were pain and fever in 21 patients (64%) and fever alone in 8 patients (24%). Suprarenal fixation was present in 20 of 33 endografts (60%). All patients underwent endograft explantation, with bowel resection in 12 patients (36%) presenting with an endograft-enteric fistula. Methods of reconstruction were graft placement in situ in 30 patients and extra-anatomic bypass in 3 patients. In situ conduits were aortic cryopreserved allografts in 23, polyester silver graft in 5, and autogenous femoral vein in 2. Microbiology specimens obtained from the endograft and the aneurysm were positive in 24 patients (74%). Gram-positive organisms were the most commonly found in 18 patients (55%). Early mortality (30 days or in the hospital) was 39% (n ¼ 13) in relation to graft blowout (n ¼ 3), multiple organ failure (n ¼ 6), colon necrosis (n ¼ 3), and peripheral embolism (n ¼ 1). At 1 year, the rates of patient survival, graft-related complications, and reinfection were 44%, 10%, and 5%, respectively. Conclusions: Abdominal aortic endograft explantation for infection is high risk and associated with graft-enteric fistula in one-third of the cases. Larger multicenter studies are needed to better understand the risk factors and to improve preventive measures at index EVAR and during follow-up.
Endografts for the Treatment of Aortic Infection
Seminars in Vascular Surgery, 2011
Aortic infection is an uncommon but life-threatening condition. Conservative medical treatment is insufficient in many cases because of the high risk of persistent infection, aortic rupture, and death. Conventional open surgical treatment consists of extensive tissue debridement, complete removal of the infected prosthetic material, and arterial reconstruction with anatomical or extra-anatomical bypass. This treatment is associated with significant morbidity and mortality; in order to avoid these, minimally invasive options with endovascular aneurysm repair have been attempted. Endovascular repair is minimally invasive and provides rapid aneurysm exclusion and prompt control of bleeding in the face of hemodynamic instability. Despite this, a major concern is the risk associated with endograft placement in an infected bed, leading to controversy about the wisdom of using endovascular aneurysm repair in this setting for mid-and long-term periods. The rate of recurrent infection is unclear because the majority of information exists in exceptional single cases or short-term series, while unsuccessful results with this approach are less likely to be reported. This review aims to assess the role of endovascular therapy for aortic infections, including its applicability as definitive or bridge repair in mycotic aneurysm, aortobronchial, aortoesophageal, and aortoenteric fistulas, in terms of both primary and secondary outcomes (ie, after previous open or endovascular aneurysm repair).
Treatment of Aortic Graft Infection in the Endovascular Era
Current Infectious Disease Reports, 2017
Purpose of Review This review provides an overview of the current literature surrounding the medical and surgical treatment of aortic graft infection with particular focus on the role of endovascular aortic grafts in the changing demographics and management of these infections. Recent Findings Definitive therapy for aortic graft infection continues to include parenteral antibiotics and surgical explantation and revascularization procedures, which are historically vast operations and sources of significant operative stress. Surgical management has evolved to include more options for infection resistant in situ conduits, attempts at partial explantations, and use of endovascular therapy to temporize the urgent sequelae of these infections, such as aortoenteric fistula. Summary Aortic graft infection continues to be a significant and morbid complication of graft placement even with the advent of endovascular therapy, and its treatment will only increase in difficulty as a more frail population has gained access to complex aortic repair. In the future, more flexible revascularization and partial explantation options are keys, along with long-term suppressive antibiotics where appropriate.
Treatment strategies and outcomes in patients with infected aortic endografts
Journal of Vascular Surgery, 2013
Objective: 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. Methods: Twenty-four patients were treated between January 1997 and July 2012. End points were mortality, morbidity, graft-related complications, or reinfection. Results: 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. Conclusions: 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.
Aortic endograft infection: A report of 2 cases
International Journal of Surgery, 2010
Introduction: Endograft infection has received less attention than other complication, so that little is known about the general features, risk factors, and treatment. The purpose of this short series is to examine our experience of infective complications after EVAR. Material and methods: Between November 2000 and December 2008, 247 patients underwent endograft repair for abdominal aortic aneurysm. Follow-up protocol included clinical visit and computed-tomography angiography 1, 4 and 12 months after the intervention, and yearly thereafter. No duplex control was performed on a regular basis. Results: Median follow-up was 16 months (range, 3e92); two patients (2/244, 0.8%) developed an endograft infection, 12 and 36-months after the intervention respectively. On admission, both patients complained septic-like fever and abdominal discomfort; leukocytes-labelled scans did not reveal pathologic traits whereas spiral computed-tomography confirmed the suspicious of endograft infection. They underwent endograft removal and extra-anatomic axillo-bifemoral bypass ; both survived and are still alive 12 and 6-months after the intervention. Isolated microorganisms were Candida albicans and Escherichia coli in one patient, and Haemophilus aphrophilus in the other. Conclusion: Endograft infection is an uncommon occurrence, Spiral computed-tomography seems to be an essential diagnostic tool. Graft removal was successful in our high-risk patients. A multicenter registry should be started to define guidelines.
Secondary Infections of Thoracic and Abdominal Aortic Endografts
Journal of Vascular and Interventional Radiology, 2009
To review several cases of stent-graft infection with respective outcomes to identify clinical presentations and responses to treatment options.The authors performed a single-center retrospective review of all secondary endograft infections from January 2000 to June 2007. Infections were identified from an institutional database containing all abdominal and thoracic endovascular aneurysm repairs (EVAR and TEVAR) performed at the treating hospital.From January 2000 to June 2007, 389 EVAR and 105 TEVAR were performed at the treating hospital. Ten endograft infections were identified (five EVAR and five TEVAR). Four infections occurred in grafts placed at outside institutions and six in grafts placed in-house. The in-house prevalence of EVAR and TEVAR infection is 0.26% and 4.77%, respectively. None were placed for a presumed pre-existing mycotic aneurysm. The mean time from the index procedure to the diagnosis of infection was 243.6 days ± 74.5. Two patients who underwent EVAR presented with a contained rupture, and the remaining eight patients presented with constitutional symptoms and/or abscess formation on imaging studies. Microbiology cultures revealed Propionibacterium species (n = 3), Staphylcoccus species (n = 3), Streptococcus species (n = 2), and Enterobacter cloacae (n = 1). All EVAR patients underwent removal of the infected endograft and reconstruction with extraanatomic bypass (n = 3) or in situ homograft placement (n = 2). During a mean follow-up of more than 1 year, there were no recognized complications or recurrence of infection. Only one of the five TEVAR patients underwent removal and interposition grafting with an antibiotic-impregnated Dacron graft. The remaining four patients were medically managed—one patient survived and was placed in hospice care, two died of mycotic aneurysm rupture, and one died from multiorgan system failure secondary to sepsis.Graft-related septic complications following EVAR or TEVAR are rare but associated with significant mortality. Several surgical treatment options are available, each potentially equally successful. The effect of prophylactic antibiotic use during subsequent invasive procedures must be solidified.
European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery, 2015
The introduction of endovascular techniques has had a major impact on the case mix of patients that undergo open aortic reconstruction. Hypothetically, this may also have increased the incidence of aortic graft infection (AGI). The aim of this study was to report on the short and mid-term incidence of AGI after primary open prosthetic aortic reconstruction in the endovascular era. From 2000 to 2010, all 514 patients in a tertiary referral university hospital, undergoing primary open prosthetic aortic reconstruction for aneurysmal or occlusive aortic disease with at least one aortic anastomosis were included. Data were obtained by retrospectively analyzing the medical records, by contacting patients or their general practitioner by telephone, and by merging the dataset with the national Cause of Death Register. AGI was defined as proven by cultures or clinically in combination with positive imaging results. The 30 day, 1 year, and 2 year incidence rates were computed using life table...
Graft infection after endovascular abdominal aortic aneurysm repair
Journal of Vascular Surgery, 2011
Introduction: Although the natural history and management of infected open abdominal aortic aneurysm (AAA) repair is well described, only sporadic case reports have described the fate of patients with infected endografts placed in the abdominal aorta. The present study describes a tertiary referral center's experience with infected endovascular aneurysm repairs (EVARs). Methods: The medical records of 1302 open and endovascular aortic procedures were queried from January 2000 to January 2010. The cases were reviewed for prior aortic procedures, prosthetic implants, and etiology of current open procedure. Demographics, operative details, and perioperative courses were documented. Results: Nine patients (1 woman) with a mean age of 71 years had an EVAR that later required an open procedure for explantation and surgical revision for suspected infection. All grafts were explanted through a midline transperitoneal approach, with a mean time to explant of 33 months. The explanted endografts included 4 Zenith (Cook, Bloomington, Ind), 2 Ancure (Endovascular Technologies, Menlo Park, Calif), 2 Excluders (Gore, Flagstaff, Ariz), and 1 AneuRx (Medtronic, Minneapolis, Minn). Eight of the nine original EVARs were performed at other hospitals; 1 patient had EVAR and open explant at the University of Michigan. All patients had preoperative computed tomography scans, except one who was transferred in extremis with a gastrointestinal hemorrhage. Three patients also had a tagged leukocyte scan, and two had magnetic resonance imaging to further reinforce the suspicion of infection before explantation and bypass planning. Rifampin-soaked Hemashield (Boston Scientific) in situ grafts were used in four patients, with extra-anatomic (axillary-bifemoral) bypass used in the other five. The in situ group had no positive preoperative or postoperative cultures, with the exception of the unstable patient who died the day of surgery. For the other five patients, positive tissue cultures were found for Bacteroides, Escherichia coli, coagulase-negative Staphylococcus, Streptococcus, and Candida. Three patients were found to have aortic-enteric fistula, two of whom died before discharge from the hospital. The remaining seven survived to discharge. Average length of stay was 22 days, with a median follow-up of 11 months. Conclusion: This series of infected EVARs is the largest group of infected AAA endografts reported to date. Because EVAR of AAAs is presently the most common method of repair, development of endograft infection, while rare, can be managed with acceptable mortality rates. Patients presenting with aortic-enteric fistula after EVAR appear to have a more virulent course.