title: A multicenter experience with infected abdominal aortic endograft explantation.
abstract: OBJECTIVE
  Endovascular aneurysm repair (EVAR) is widely used with excellent results, but its infectious complications can be devastating. In this paper, we report a multicenter experience with infected EVAR, symptoms, and options for explantation and their outcome.
  
  
  METHODS
  We have reviewed all consecutive endograft explants for infection at 11 French university centers following EVAR, defined as index EVAR, from 1998 to 2015. Diagnosis of infected aortic endograft was made on the basis of clinical findings, cultures, imaging studies, and intraoperative findings.
  
  
  RESULTS
  Thirty-three patients with an infected aortic endograft were identified. In this group, at index EVAR, six patients (18%) presented with a groin or psoas infection and six patients (18%) presented with a general infection, including catheter-related infection (n = 3), prostatitis (n = 1), cholecystitis (n = 1), and pneumonia (n = 1). After index EVAR, eight patients underwent successful inferior mesenteric artery embolization for a type II endoleak within 6 months of index EVAR and one patient received an additional stent for a type Ib endoleak 1 week after index EVAR. Median time between the first clinical signs of infection and endograft explantation was 30 days (range, 1 day to 2.2 years). The most common presenting characteristics were pain and fever in 21 patients (64%) and fever alone in 8 patients (24%). Suprarenal fixation was present in 20 of 33 endografts (60%). All patients underwent endograft explantation, with bowel resection in 12 patients (36%) presenting with an endograft-enteric fistula. Methods of reconstruction were graft placement in situ in 30 patients and extra-anatomic bypass in 3 patients. In situ conduits were aortic cryopreserved allografts in 23, polyester silver graft in 5, and autogenous femoral vein in 2. Microbiology specimens obtained from the endograft and the aneurysm were positive in 24 patients (74%). Gram-positive organisms were the most commonly found in 18 patients (55%). Early mortality (30 days or in the hospital) was 39% (n = 13) in relation to graft blowout (n = 3), multiple organ failure (n = 6), colon necrosis (n = 3), and peripheral embolism (n = 1). At 1 year, the rates of patient survival, graft-related complications, and reinfection were 44%, 10%, and 5%, respectively.
  
  
  CONCLUSIONS
  Abdominal aortic endograft explantation for infection is high risk and associated with graft-enteric fistula in one-third of the cases. Larger multicenter studies are needed to better understand the risk factors and to improve preventive measures at index EVAR and during follow-up.
authors.affiliation: Department of Vascular Surgery, University of Toulouse, Toulouse, France.
authors.forename: Xavier
authors.initials: X
authors.lastname: Chaufour
authors.affiliation: Department of Vascular Surgery, Hôpital Pitié-Salpétrière, Paris, France.
authors.forename: Julien
authors.initials: J
authors.lastname: Gaudric
authors.affiliation: Department of Vascular Surgery, University of Nantes, Nantes, France.
authors.forename: Yann
authors.initials: Y
authors.lastname: Goueffic
authors.affiliation: Department of Vascular Surgery, University of Nice, Nice, France.
authors.forename: Réda Hassen
authors.initials: RH
authors.lastname: Khodja
authors.affiliation: Department of Vascular Surgery, University of Lyon, Lyon, France.
authors.forename: Patrick
authors.initials: P
authors.lastname: Feugier
authors.affiliation: Department of Vascular Surgery, University of Nancy, Nancy, France.
authors.forename: Sergei
authors.initials: S
authors.lastname: Malikov
authors.affiliation: Department of Infectious Diseases, University of Poitiers, Poitiers, France.
authors.forename: Guillaume
authors.initials: G
authors.lastname: Beraud
authors.affiliation: Department of Vascular Surgery, University of Poitiers, Poitiers, France. Electronic address: jeanbaptistericco@gmail.com.
authors.forename: Jean-Baptiste
authors.initials: JB
authors.lastname: Ricco
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D006801:Humans; D008297:Male; D008875:Middle Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery; D001027:Aortography / Q000379:methods; D001431:Bacteriological Techniques; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D000072226:Computed Tomography Angiography; D020878:Device Removal / Q000009:adverse effects / Q000379:methods / Q000401:mortality; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005268:Femoral Vein / Q000637:transplantation; D005602:France; D017052:Hospital Mortality; D006785:Hospitals, University; D053208:Kaplan-Meier Estimate; D011474:Prosthesis Design; D016459:Prosthesis-Related Infections / Q000000981:diagnostic imaging / Q000382:microbiology / Q000401:mortality / Q000601:surgery; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents