title: Comparison of treatment strategies for thoracic endograft infection.
abstract: OBJECTIVE
  Endograft infection after thoracic endovascular aortic repair (TEVAR) is associated with a substantial mortality rate that exceeds 70% in the largest published series. The aim of this study was to review all published reports on infection after TEVAR treated with either preservation of the endograft or surgical excision of the stent graft with the intention of providing a comparison of the safety, efficacy, and durability of the two different treatment strategies.
  
  
  METHODS
  An extensive electronic health database search was undertaken to identify all articles that were published up to December 2013 reporting on endograft infection after TEVAR. Overall, 55 patients treated with endograft preservation (group A) and 41 patients treated with endograft explantation (group B) were included in this review.
  
  
  RESULTS
  The most frequently isolated microorganisms were Streptococcus species (29.4%) and Staphylococcus species (29.4%). The mortality for both groups was 66.6%. The in-hospital mortality rate in group A was 42% and reached 81.8% in a mean follow-up period of 8.6 months. The in-hospital mortality rate in group B was 36.6%. Four (9.7%) further deaths due to reinfection or fistula recurrence were recorded in a mean follow-up period of 15.3 months, leading to an overall mortality of 46.3%. The meta-analysis showed a trend of better outcome with endograft explantation compared with endograft preservation (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.18-1.48). In group A, a trend of better outcome was revealed when drainage and repair of the fistula were applied (OR, 2.22; 95% CI, 0.55-8.90). A trend of worse outcomes was detected in fistula patients compared with nonfistula patients (OR, 1.26; 95% CI, 0.43-3.74).
  
  
  CONCLUSIONS
  Endograft preservation seems not a durable option. It can be offered to patients who refuse surgery or as a palliative option or bridging procedure for severely ill patients. Compared with antibiotic therapy alone, antibiotic therapy followed by drainage and repair of the fistula may control the sepsis, providing, however, mainly a temporary benefit. The presence of fistula is a predictor of dismal outcome. Endograft explantation remains the "gold standard" of treatment. The mortality rate of surgical conversion is much higher in the presence of fistula.
authors.affiliation: Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece. Electronic address: konmoulakakis@yahoo.gr.
authors.forename: Konstantinos G
authors.initials: KG
authors.lastname: Moulakakis
authors.affiliation: Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece.
authors.forename: Spyridon N
authors.initials: SN
authors.lastname: Mylonas
authors.affiliation: Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece.
authors.forename: Constantine N
authors.initials: CN
authors.lastname: Antonopoulos
authors.affiliation: Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece.
authors.forename: John D
authors.initials: JD
authors.lastname: Kakisis
authors.affiliation: Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece.
authors.forename: George S
authors.initials: GS
authors.lastname: Sfyroeras
authors.affiliation: Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece.
authors.forename: George
authors.initials: G
authors.lastname: Mantas
authors.affiliation: Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece.
authors.forename: Christos D
authors.initials: CD
authors.lastname: Liapis
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D001807:Blood Vessel Prosthesis / Q000009:adverse effects*; D020878:Device Removal / Q000379:methods*; D057510:Endovascular Procedures / Q000009:adverse effects*; D006801:Humans; D017410:Practice Guidelines as Topic; D016459:Prosthesis-Related Infections / Q000628:therapy*
chemical_list: D000900:Anti-Bacterial Agents