Native and prosthetic graft infections of the thoracic aorta: surgical management

Abstract

OBJECTIVES Infection of the native aorta or after previous open or endovascular repair of the thoracic aorta is associated with high risks for morbidity and mortality. We analysed the outcome after surgical management of a native mycotic aneurysm or of prosthetic graft infection of the descending aorta. METHODS From June 2000 to May 2019, a total of 39 patients underwent surgery in our centre for infection of the native descending aorta (n = 19 [49%], group A) or a prosthetic descending aorta [n = 20 (51%), group B]. In the 20 patients in group B, a total of 8 patients had prior open aortic repair with a prosthesis and 12 patients had a previous endovascular graft repair. RESULTS The cohort patients had a mean age of 57 ± 14; 62% were men (n = 24). The most common symptoms at the time of presentation included fever, thoracic or abdominal pain and active bleeding. Emergency surgery was performed in 11 patients (28%); 3 patients had emergency endovascular stent grafts implanted during thoracic endovascular aortic repair for aortic rupture before further open repair. The 30-day mortality was 42% in group A and 35% in group B. The 90-day mortality was 47% in group A and 45% in group B. Pathogens could be identified in approximately half of the patients (46%). The most commonly identified pathogens were Staphylococcus aureus in 6 patients (15%) and Staphylococcus epidermidis in 4 patients (10%). Survival of the entire group (including patients with both native and prosthetic graft infections) was 44 ± 8%, 39 ± 8% and 39 ± 8% at 1, 2 and 3 years after surgery. The percentage of patients who survived the initial perioperative period was 81 ± 9%, 71 ± 9% and 71 ± 10% at 1, 2 and 3 years after surgery. CONCLUSIONS Patients with infection of the descending aorta, either native or prosthetic, are associated with both high morbidity and mortality. However, patients who survive the initial perioperative period have an acceptable long-term prognosis. In emergency situations, thoracic endovascular aortic repair may help to stabilize patients and serve as bridge to open repair.

Vascular graft infections

“…In general, the literature regarding the management of thoracic VGIs is scanty, and most of the available documents are surgical case series or retrospective studies with a limited number of patients [21,64,77,79] . Currently, and as a natural consequence of broader use of TEVAR compared to open repair, infected endografts are more commonly observed and reported [80] . Kahlberg et al [60] studied outcomes for open surgical grafts and endograft infections.…”

“…Aorto-esophageal (AEF) or aorto-bronchial fistula (ABF) are reported in up to 1.5% of treated patients [80,83] . Czerny et al [84,85] from an international collaboration group found 1.5% AEF and 0.56% ABF.…”

Alternative Nuclear Imaging Tools for Infection Imaging

“…Defining the location and extent of infection and the status of surrounding tissue is crucial for the subsequent treatment planning. In particular, proper diagnosis of infection limited to the vascular portion of the thoracic aortic grafts (VPI, about 2%) [ 62 ] is critical due to the high mortality associated with replacement of the graft, especially in patients with long-lasting infections or severe co-morbidities. Alternative options such as graft salvage through aggressive debridement and irrigation or non-surgical management with antibiotics alone [ 63 ] can be considered.…”