title: A multicenter experience with the surgical treatment of infected abdominal aortic endografts.
abstract: OBJECTIVE
  Single-center experiences with the treatment of infected endografts after endovascular aortic repair (I-EVAR) have been reported. We performed a multicenter review of the surgical care of these patients to elucidate short-term and long-term outcomes.
  
  
  METHODS
  A retrospective analysis of all EVAR explants from 1997 to 2014 at four institutions was performed. Patients with I-EVAR undergoing surgical treatment were reviewed. Data were obtained detailing preoperative demographics, and postoperative morbidity and mortality.
  
  
  RESULTS
  Thirty-six patients (30 male) were treated with endovascular graft excision and revascularization for I-EVAR with a median age of 69 years (range, 54-80 years). Average time from the initial EVAR to presentation was 589 days (range, 43-2466 days). Preoperative comorbidities included hypertension, 32 (89%); tobacco use, 31(86%); coronary artery disease, 26 (72%); hyperlipidemia, 25 (69%), peripheral artery disease, 13 (36%); cerebrovascular disease, 10 (28%); diabetes, 10 (28%); chronic obstructive pulmonary disease, 9 (25%); and chronic kidney disease, 9 (25%). The most common presenting patient characteristics were leukocytosis, 23 (63%); pain, 21 (58%); and fever, 20 (56%), which were present an average of 65 days (range, 0-514 days) before explantation. Nine different types of endograft were removed. Three patients (8%) underwent emergency explantation. Thirty-four patients (89%) underwent total graft excision, and two patients (6%) underwent partial excision. Methods of reconstruction were in situ in 27 (75%) and extra-anatomic in nine (28%). Conduits used were Dacron (DuPont, Wilmington, Del), with or without rifampin, polytetrafluoroethylene, cryopreserved allograft, and femoral vein. Forty-nine organisms grew from operative cultures. Gram-positive organisms were the most common, found in 24 (67%), including Staphylococcus in 13 (36%) and Streptococcus in six (17%). Anaerobes were cultured in 6 patients (17%), gram-negative organisms in 6 (17%), and fungus in 5 (14%). Thirty-one patients (86%) received long-term antibiotics. Early complications included acute renal failure requiring dialysis, 12 (33%); respiratory failure, 3 (8%); bleeding, 4 (11%); and sepsis, 2 (6%). Six patients required re-exploration due to hematoma, infected hematoma, lymphatic leak, bowel perforation, open abdomen at initial operation, and anastomotic bleeding. Perioperative mortality was 8% (3 of 36), and long-term mortality was 25% (9 of 36) at a mean follow-up of 569 days (range, 0-3079 days). Type of reconstruction (in situ vs extra-anatomic) or conduit type did not affect perioperative or overall mortality.
  
  
  CONCLUSIONS
  I-EVAR is a rare but potentially devastating clinical problem. Although perioperative mortality is acceptable, long-term mortality is high. The most common postoperative complication was acute renal failure requiring dialysis. Although this is the largest series of I-EVAR, further studies are needed to understand the risk factors and preventive measures.
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Ariz.
authors.forename: Victor J
authors.initials: VJ
authors.lastname: Davila
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Ariz.
authors.forename: William
authors.initials: W
authors.lastname: Stone
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Audra A
authors.initials: AA
authors.lastname: Duncan
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Mayo Clinic, Rochester, Minn.
authors.forename: Emily
authors.initials: E
authors.lastname: Wood
authors.affiliation: Division of Vascular Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala.
authors.forename: William D
authors.initials: WD
authors.lastname: Jordan
authors.affiliation: Division of Vascular Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Zea
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, La.
authors.forename: W Charles
authors.initials: WC
authors.lastname: Sternbergh
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, Ariz. Electronic address: money.samuel@mayo.edu.
authors.forename: Samuel R
authors.initials: SR
authors.lastname: Money
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001012:Aorta, Abdominal / Q000601:surgery; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D015897:Comorbidity; D057510:Endovascular Procedures; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016459:Prosthesis-Related Infections / Q000382:microbiology / Q000401:mortality / Q000601:surgery*; D012086:Reoperation; D012189:Retrospective Studies