title: Treatment strategies and outcomes in patients with infected aortic endografts.
abstract: 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.
authors.affiliation: Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN 55905, USA.
authors.forename: Javairiah
authors.initials: J
authors.lastname: Fatima
authors.forename: Audra A
authors.initials: AA
authors.lastname: Duncan
authors.forename: Eileen
authors.initials: E
authors.lastname: de Grandis
authors.forename: Gustavo S
authors.initials: GS
authors.lastname: Oderich
authors.forename: Manju
authors.initials: M
authors.lastname: Kalra
authors.forename: Peter
authors.initials: P
authors.lastname: Gloviczki
authors.forename: Thomas C
authors.initials: TC
authors.lastname: Bower
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001014:Aortic Aneurysm / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis / Q000009:adverse effects*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation / Q000401:mortality; D020099:Coated Materials, Biocompatible; D020878:Device Removal / Q000009:adverse effects / Q000401:mortality; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000295:instrumentation / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011474:Prosthesis Design; D011475:Prosthesis Failure; D016459:Prosthesis-Related Infections / Q000175:diagnosis / Q000382:microbiology / Q000401:mortality / Q000601:surgery*; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D013203:Staphylococcal Infections / Q000175:diagnosis / Q000382:microbiology / Q000401:mortality / Q000601:surgery*; D013290:Streptococcal Infections / Q000175:diagnosis / Q000382:microbiology / Q000401:mortality / Q000601:surgery*; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D020099:Coated Materials, Biocompatible