Treatment of Aortic Graft Infection in the Endovascular Era

Abstract

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. 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.

Endograft Infection Due to Secondary Aortoenteric Fistula Treated With Custom-Made Bovine In Situ Aortic Bifurcation Graft

“…6,11 Symptoms of stent graft infection and AEF include chronic fever, abdominal pain, leukocytosis, bacteremia, weight loss, weakness, and bleeding, but reportedly 10% of patients remain asymptomatic. 3,6,12 Chaufour et al reported a median time from initial EVAR and first signs of infection of 414 days (range up to 9 years) and a median time to endograft explantation of 30 days (range up to 2.2 years). 2 In addition to CT scans, FDG-PET scans and leukocyte scintigraphy show higher sensitivity and may provide further information to assess the extent and origin of a suspected inflammatory process.…”

“…[4][5][6][7] A prophylactic systematic antibiotic therapy prior to any procedure or illness (ie, urinary tract infection, pneumonia, and dental treatment) following EVAR has been recommended to avoid potential endograft contamination. 2,5 An in situ reconstruction, with previous complete endograft removal and removal of necrotic tissue, provides an alternative approach, avoiding most of the risks of extra-anatomic technique 6,12,13 but still facing high risk of reinfection. Autologous veins and cryopreserved allografts bear a risk of rupture, aneurysm formation, thrombosis, and occlusion but are considered favorable over prosthetic grafts (eg, rifampicin-soaked Dacron) that are associated with reinfection rates.…”

“…15 Previous publications match our intraoperative findings of inflammation involving the pararenal region and signs of steady minimal inflammation surrounding the endograft in follow-up CT scans after initial EVAR. 1,2,5,7,8,12,14,16 Nonetheless, a multicenter study stated findings of more extensive presence of inflammation during surgical SAEF repair in patients with an initially open surgical approach, compared to previous EVAR. 6 Reports also second our discovery of the AEF developing at the level of the aneurysm sac, rather than the proximal parts of the endograft containing hooks and hence supporting theories of an inflammatory etiology.…”

“…Symptoms of stent graft infection and AEF include chronic fever, abdominal pain, leukocytosis, bacteremia, weight loss, weakness, and bleeding, but reportedly 10% of patients remain asymptomatic. 3,6,12 Chaufour et al reported a median time from initial EVAR and first signs of infection of 414 days (range up to 9 years) and a median time to endograft explantation of 30 days (range up to 2.2 years). 2…”

Successful Treatment of an Infected Zenith Fenestrated Endograft Without Explantation

“…3 However, the presence of an aortoenteric fistula (AEF), a poor prognosticator, concurrent with a fenestrated aortic endograft explantation may further increase perioperative mortality to prohibitive levels. 4…”