Aortic endograft infection: A report of 2 cases (original) (raw)
Related papers
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.
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.
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-...
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.
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.
2016
Even though aggressive surgical management is recommended for most cases of aortic endoprosthesis infection, because of the high surgical risk presented, conservative treatment should also be considered in selected cases. We present here a clinical case of a 84-year-old patient, presenting with low back pain, fever and weight loss for two months. He had undergone an endovascular infra renal aortic aneurysm repair three years ago. A computed tomography scans demonstrated bubbles inside the sac and a perianeurysmatic collection. A puncture of this collection was undertaken and the diagnosis of aortic endograft infection, caused by Propionibacterium sp, was made. The patient was successfully managed conservatively with parenteral followed by long-term oral antibiotic therapy.
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.
Annals of vascular surgery, 2015
to preliminary report on epidemiology, risk factors, diagnosis, treatments and outcomes in a multicenter series of patients treated for EVAR infection and detected by a Italian National enquiry METHODS: From June 2012 twenty-six cases of abdominal aortic endograft infection were collected by a National Enquiry and recorded in the Italian National Registry of Infection in EVAR (R.I.-EVAR). Cases collected were available for patients submitted to EVAR implantation from January 2004 to June 2013. Mean time from EVAR treatment to infection diagnosis was 20.5±20.3 months (range 1-72). In 6 cases (23.1%) an aorto-enteric fistula (AEF) was detected. Positive microbiological cultures were found in 20 patients (76.9%). More than 1 infectious agent was found in 6 cases (19.2%). EVAR infection treatment was conservative in 4 cases, endovascular in 2. Endograft excision was performed in 10 cases by conventional treatment (aortic stump+extra-anatomic bypass) and in 10 cases by in situ reconstruc...
EJVES Extra, 2005
Endograft infection is a rare event, with few reports in the literature. This report describes delayed infection of an aortic endoprosthesis that eventually resulted in abdominal aortic aneurysm (AAA) rupture. The procedure was performed in an angiographic suite. In the postoperative period the patient developed a central venous line infection. This appears to be the first recognized and reported case in which the infected aortic neck completely dilated due to the radial force of the stent graft.