Elsevier

Annals of Vascular Surgery

Volume 76, October 2021, Pages 254-268
Annals of Vascular Surgery

Clinical Research
Treatment and Outcomes of Aortic Graft Infections Using a Decision Algorithm

https://doi.org/10.1016/j.avsg.2021.04.047Get rights and content

Background

Aortic graft infection (AGI) is a rare but devastating complication requiring both explant of the infected prosthesis and lower extremity revascularization. Despite a variety of methods to treat AGI, there is a paucity of evidence that describes comparative outcomes. Moreover, controversy exists surrounding what the optimal repair strategy is with limited descriptions of how these techniques should be employed in this complex group of patients. Therefore, the purpose of this analysis was to review our experience with AGI management while highlighting a practice philosophy that can achieve acceptable outcomes.

Methods

All AGI patients between 2002-2019 were reviewed. The primary end-point was 30-day mortality. Secondary end-points included complications, re-infection, unplanned re-operation and all-cause mortality. Kaplan-Meier methodology was used to estimate time to events. Cox regression models were employed to identify association between patient factors and operative strategy with survival. Subgroup analysis included outcome comparison among four different operative approaches(extra-anatomic bypass with aortic ligation [EAB] and in-situ reconstruction [ISR] using either NAIS, cryopreserved allograft [Cryo], or antibiotic-soaked prosthetic grafts [Other]).

Results

142 patients (male-69%, mean age 67 ± 11 years) were reviewed. Median time to AGI presentation was 52 (IQR 16-128) months. ISR was performed in 70% (n = 99)[ISR: NAIS-49% (n = 49), Cryo, 33% (n = 33) and Other-23% (n = 23)]. EAB was used in 26% (n = 37), of which 57% (n = 21) were staged repairs[no reconstruction, 4%: intraoperative death-2, AGI removal without reconstruction-2]. A graft enteric erosion/fistula was identified in 39% (n = 55).

Mean follow-up time was 14 ± 27 (median 2.2[IQR 0.1-16]) months. Overall, 30-day mortality was 21% and 69% (n = 98) experienced a complication. The most common complications were pulmonary (35%;n = 50), vascular (28%;n = 39), gastrointestinal (22%;n = 31) and renal (21%;n = 30). Freedom from re-infection at one and three years was 78 ± 5% and 73 ± 6% while freedom from unplanned re-operation was 50 ± 5% and 40 ± 6%, respectively. Corresponding one- and five-year freedom from all-cause mortality was 67 ± 4% and 53 ± 4%.

When stratified by the four different repair strategies, unadjusted rates of postoperative complications and mortality were not different. However, EAB patients had more renal complications. All-cause mortality predictors included age (HR 1.04, 95%CI 1.01–1.1; P = 0.003), CHF (HR 2.7, 1.3–5.7; P = 0.01), and graft enteric erosion/fistula (HR 2.2, 1.3–3.8;P = 0.005) while total graft excision was protective (HR 0.34, 0.2–0.7; P = 0.003).

Conclusions

AGI repair, regardless of operative strategy, results in significant early morbidity, and mortality. The need for unplanned re-operation is common; however, long-term survival is acceptable in appropriately selected patients. Re-infection risk mandates life-long surveillance and consideration of indefinite anti-microbial suppression in certain subgroups. Due to the complexity and intensity of care, all AGI should be treated, when possible, at centers performing high-volume aortic surgery.

Section snippets

INTRODUCTION

Aortic graft infection(AGI) is a rare but devastating complication that usually mandates extirpation of the infected prosthesis and some method of lower extremity revascularization.1., 2., 3., 4., 5., 6., 7., 8. Despite a variety of techniques to treat AGI, there is a paucity of evidence describing comparative effectiveness of different management strategies.2,3,6 This shortcoming is related to the absence of randomized controlled trials to govern clinical decisions, which are largely

MATERIAL AND METHODS

This study was approved by the Institutional Review Board at the University of Florida College of Medicine (IRB# 2230-2019). The need for patient consent was waived due to the minimal risk and retrospective nature of the study.

Study design and database. The institutional data repository research query included the following criteria: procedure occurring between 2002–2019, including one of the following (partial) keywords: “infect”, “excise”, and classified within the database as one of the

DISCUSSION

The current analysis highlights contemporary results for surgical management of AGI. Herein, we provide a detailed description of a decision-algorithm, that when consistently applied, led to acceptable outcomes for one of the most difficult problems vascular surgeons manage. Specifically, a variety of different reconstruction strategies, conduit choices, and operative sequences were employed to effectively manage AGI. Importantly, this series also presents a comparative description of

CONCLUSIONS

AGI results in significant early morbidity and mortality and the need for re-operative procedures is common; however, long-term survival is good in appropriately selected patients. The risk of late re-infection mandates lifelong surveillance and targeted anti-microbial suppression strategies. Management of AGI using multiple operative approaches can result in acceptable and predictable results for most outcomes when occurring at a center with experience managing complex aortic disease that uses

REFERENCES (26)

Cited by (8)

  • Psoas Muscle Area as a Prognostic Factor for Survival in Patients Undergoing Endovascular Aneurysm Repair Conversion

    2022, Annals of Vascular Surgery
    Citation Excerpt :

    The details regarding patient selection, risk stratification principles, technical features, and perioperative care routines for EVAR-c patients at our institution have been previously published.6 In procedures where infection was the indication, total stent-graft explant occurred (Fig. 2A), but in selected cases without evidence of infection, subtotal extirpation was commonly utilized depending on aneurysm morphology and endograft characteristics, as previously described.6,24 Specifically, proximal endograft trans-renal fixation elements and frequently the distal iliac limbs were incorporated into the aortic and iliac anastomotic sewing rings (Fig. 2B).

  • Infected abdominal aortic endograft with Propionibacterium acnes: A case report

    2022, Annals of Vascular Surgery - Brief Reports and Innovations
  • Invasive non-typhoidal Salmonella infection complicated by metastatic infections: Report of three cases

    2022, IDCases
    Citation Excerpt :

    In critical cases, one could therefore rely on antimicrobials to minimize the risk related to surgery. This was the case of the second patient discussed in the present report [14]. In this patient, the course of antimicrobial treatment continues up to four years after the initial diagnosis.

View all citing articles on Scopus

Conflicts of Interest: The authors have no relevant conflicts of interest.

Funding: This research was not supported by any specific grant from a funding agency in the public, commercial, or not-for-profit sectors.

Meeting Presentation: This work was presented at the 44th Annual Meeting of the Vascular and Endovascular Surgery Society (VESS) January 30 - February 2, 2020 at The Steamboat Grand in Steamboat Springs, CO.

a

Shared 1st authorship

View full text