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The Management of Endograft Infections Following Endovascular Thoracic and Abdominal Aortic Aneurysm Repair
Erin H. Murphy, MD, Benjamin J. Herdrich, MD, Benjamin M. Jackson, MD, Grace J. Wang, MD, Alberto Pochettino, MD, Wilson Y. Szeto, MD, Joseph E. Bavaria, MD, William Moser, RN, Ronald M. Fairman, MD, Edward Y. Woo, MD.
Hospital of the Univerity of Pennyslvania, Philadelphia, PA, USA.
Objective: The management of infected aortic endografts is a challenging endeavor. Treatment of this problem has not been well defined as it is fairly uncommon. However, the incidence is increasing. This study examines the results of treatment at a single center for this morbid process.
Methods: A retrospective review was performed of patients treated for infected abdominal or thoracic endograft infection following previous EVAR or TEVAR. Data was reviewed for patient demographics, details of initial endograft implantation, presentation and timeline of subsequent infection, management of infected grafts, and outcomes during follow-up.
Results: Between 2000-2006, 2 patients were treated for infected endografts. However, from 2006-2011, 14 patients underwent treatment. Sixteen patients in total were treated (thoracic:4, abdominal:12). Mean time to presentation with infection from endograft implant was 208 days, with over half (56%) presenting within the first 3 months. Tissue and/or blood cultures were positive in 12/16 growing E.Coli (n=1), Group A streptococcus (n=3), Methicillin-resistent-Staph Aureus (n=2) or polymicrobial infections (n=6). The other 4 patients were culture negative with CT evidence of gas surrounding the endograft and clinical sepsis. Ten patients (abdominal:8, thoracic:2) were treated with endograft explantation. The remaining six patients lacked CT evidence of advanced infection (n=3) or were considered too high-risk for explant (N=3) and were therefore managed conservatively without explant (abdominal:4, thoracic:2). Mortality was 37.5% (n=6) and was higher for thoracic stent infections (n=3, 75%)(p<0.001) and patients presenting with aorto-enteric or aorto-bronchial fistulas (n=6/9, 67%)(p<0.001). Survival was 100% (n=7) in patients without evidence of aorto-enteric or aorto-bronchial fistula. Overall survival was similar between those managed surgically (n=4,40%) or medically (n=2,33%)(p=0.81). Mean follow-up of survivors was 27.1 months. All survivors remain on long-term suppressive antibiotics. Two additional patients died of unrelated causes during follow-up.
Conclusion: Endograft infection is a rare but increasing complication after EVAR/TEVAR which carries significant associated morbidity and mortality. Aorto-enteric or aorto-bronchial fistulas are a common presentation which portends significantly worse prognoses. Surgical excision has been the standard of care but conservative management with IV antibiotics may be of benefit in certain patients.
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