Treatment and outcomes of aortic endograft infection

Objective 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). Methods 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. Results 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-(bi)femoral bypass. Graft cultures were primarily polymicrobial (35%) and gram-positive (22%). Mean hospital length of stay was 23 days, with perioperative 30-day morbidity of 35% and mortality of 11%. Of the nine patients managed only medically, four of five TEVAR patients died after mean of 56 days and two of four EVAR patients died; both deaths were graft-related (mean follow-up, 4 months). Nineteen replacement grafts were explanted after a mean of 540 days and were most commonly associated with prosthetic graft material not soaked in antibiotic and extra-anatomic bypass. Mean follow-up was 21 months, with life-table survival of 70%, 65%, 61%, 56%, and 51% at 1, 2, 3, 4, and 5 years, respectively. Conclusions Aortic endograft infection can be eradicated by excision and in situ or extra-anatomic replacement but is often associated with early postoperative morbidity and mortality and occasionally with a need for late removal for reinfection. Prosthetic graft replacement after explanation is associated with higher reinfection and graft-related complications and decreased survival compared with autogenous reconstruction.