title: Management of early graft infections in the ascending aorta and aortic arch: a comparison between graft replacement and graft preservation techniques.
abstract: OBJECTIVE
  Treatment of infected thoracic aortic grafts is associated with considerable morbidity and mortality. The replacement of an infected graft is an effective strategy, yet a complex surgical endeavour, especially if the aortic root or aortic arch is involved. In situ graft-sparing surgical therapy with continuous mediastinal irrigation after surgical debridement might offer an alternative in the management of early graft infections in the thoracic aorta.
  
  
  METHODS
  Between 1996 and August 2015, 25 patients were treated in our institution for early graft infection after thoracic aortic surgery via sternotomy. In 11 patients, the infected prosthesis was replaced by a cryopreserved homograft or a biological valved pericardial xenograft. In 14 patients, an attempt to salvage the graft was made by resternotomy, aggressive debridement and subsequent continuous mediastinal antibiotic irrigation over a course of 2 weeks, accompanied by systemic antibiotic therapy.
  
  
  RESULTS
  In-hospital mortality was comparable (replacement group: 2/11 = 18%, graft-sparing group: 2/14 = 14%, P = ns). The time interval from the initial surgery was significantly shorter in the graft-sparing group (replacement group: 165 days [range 95-300 days] and graft-sparing group: 24 days [range 15-93 days], P = 0.004]. Two patients (14%), who were treated with the graft-sparing approach >100 days after the initial surgery, were retreated for infection, and 1 due to an intra-aortic infection of an aortic arch hybrid stent graft was not amenable to external irrigation (median follow-up: 1.5 years [range 1.1-2.1 years]). One patient in the replacement group (9%) was reoperated on due to homograft degeneration (median follow-up: 6.0 years [3.0-8.9 years]).
  
  
  CONCLUSIONS
  In situ graft-sparing surgical therapy is safe and effective if diagnosis and treatment of aortic graft infection is initiated promptly and aggressively (ideally <1 month post-surgery). Our method produces good midterm results (3 years). For aortic graft infections that become clinically apparent >3-6 months after surgery, replacement of grafts with biological conduits (homografts or pericardial xenografts) most likely remains the best treatment option.
authors.affiliation: Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Julia
authors.initials: J
authors.lastname: Umminger
authors.affiliation: Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Heike
authors.initials: H
authors.lastname: Krueger
authors.affiliation: Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Erik
authors.initials: E
authors.lastname: Beckmann
authors.affiliation: Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Tim
authors.initials: T
authors.lastname: Kaufeld
authors.affiliation: Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Felix
authors.initials: F
authors.lastname: Fleissner
authors.affiliation: Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Axel
authors.initials: A
authors.lastname: Haverich
authors.affiliation: Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Malakh
authors.initials: M
authors.lastname: Shrestha
authors.affiliation: Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany martens.andreas@mh-hannover.de.
authors.forename: Andreas
authors.initials: A
authors.lastname: Martens
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001011:Aorta / Q000601:surgery*; D001013:Aorta, Thoracic / Q000601:surgery*; D003646:Debridement; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012086:Reoperation / Q000401:mortality; D012189:Retrospective Studies; D013530:Surgical Wound Infection / Q000188:drug therapy / Q000401:mortality / Q000601:surgery*; D007507:Therapeutic Irrigation; D058017:Vascular Grafting / Q000009:adverse effects* / Q000379:methods
chemical_list: D000900:Anti-Bacterial Agents
keywords: Antibiotic irrigation; Graft infection; Homograft; Thoracic aorta