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OBJECTIVES:Conventional open repair of mycotic thoracic aortic aneurysms (MTAA) is associated with high morbidity and mortality, yet this approach remains the gold standard treatment. Endovascular repair has emerged as a new option for MTAAs. However, the literature contains few reports on long-term results. This study sought to review outcomes in one of the largest series of MTAA patients treated with thoracic endovascular aortic repair (TEVAR).
METHODS: We retrospectively reviewed the records of 380 consecutive patients who underwent stent-graft repair for thoracic aortic pathology from March 2005 to February 2015. A MTAA was defined based on characteristic radiologic features and positive blood cultures. Patients who were not intended to receive a 6-week course of IV antibiotics followed by lifelong oral suppressive therapy were excluded. Primary graft infections and ascending aortic disease were also excluded.
RESULTS: Eight males and three females (n=11) were identified with MTAAs. The average age was 69 years (range, 50 to 89). Average duration of follow-up was 463 days (range, 5 to 1,670). Mean hospital and ICU stays were 17 and 5 days, respectively. Mean survival was 549 days (range, 5 to 1,670). There were no reported incidences of stroke or paraplegia. Type II endoleaks (n=2, 18.2%) were managed conservatively. A total of six patients ultimately died (54.5%) at an average follow-up of 375 days. There was one postoperative 30-day mortality (9.1%). Causes of in-hospital mortality (n=2; 18.2%) included sepsis secondary to multiple multi-drug resistant infections and acute respiratory failure from aspiration. Of the 11 MTAA patients, three succumbed to aneurysm-related disease (27.3%). Recurrent graft infection (n=1; 9.1%) occurred in a patient non-compliant with lifelong suppressive therapy, constituting the only late-term mortality attributed to endovascular intervention and associated complications. Successful exclusion and resolution of MTAA was seen in 8 patients on last follow-up imaging.
CONCLUSIONS:Endovascular stent-graft repair is a feasible treatment option for MTAAs. Despite one late-term mortality directly attributable to endovascular intervention, our data indicate potential for long-term success. Antimicrobial therapy clearly has a role in the prevention of reinfection and late graft-related complications. Most of the patients in the series had significant underlying comorbidities in addition to complex aortic disease. Early mortality decreased over the study period, suggesting continued improvement in endovascular techniques and standardized patient care could further improve outcomes.