Outcomes of open operative management of pararenal/paravisceral aortic infection
Indrani Sen, Manju Kalra, Gustavo Oderich, Thomas Bower, Peter Gloviczki.
Mayo clinic, Rochester, MN, USA.
Introduction Operative management of pararenal/paravisceral aortic infection remains technically challenging. Our aim was to evaluate outcomes of operative management in these infections. Methods: Data from consecutive patients with infection involving the pararenal/paravisceral aorta undergoing open operative intervention between 1996- 2016 were retrospectively reviewed. Clinical features, imaging, operative details and morbidity were recorded. Primary end points were mortality, reinfection and patency. Results: Of 128 patients with aortic infection, 14 (12 male, 2 female, mean age 64 years) with pararenal or paravisceral infection were identified; 4 with distal thoracic aorta involvement. There were 5 primary mycotic aneurysms, 5 infected open aortic and 4 endovascular grafts. All patients were symptomatic; 2 presented with rupture. Surgical exposure was via midline laparotomy in 8 (58%); thoracoabdominal in 6. Aortic reconstruction was extraanatomic (Fig 1) in 8 [thoracic 6, intraabdominal 2;] and in situ in 6; conduits included Rifampin soaked polyester (11) and cryopreserved arterial graft (3). Operative adjuncts were partial left heart bypass and temporary axillary-femoral bypass (1 each). Concomitant renal and visceral bypasses were performed in 7 (n=24; 7 SMA, 5 celiac, 12 renal); renal bypasses (n=9) alone in 7 patients. Intra-operative cultures were polymicrobial (4), single organism (4) and sterile (5); 11/14 received antibiotics prior to presentation. In-hospital mortality was 4/14 (28%) due to multisystem failure. Morbidity included renal dysfunction requiring dialysis in 6 (including the 4 deaths); was transient in 2. Ischemic colitis occurred in 2 patietns, limb ischemia and myocardial infarction in 1 each. Average length of stay was 23 days (10-62 days). Following 6 weeks of intravenous antibiotics all patients received long term oral antibiotic suppression. Mean clinical and imaging follow-up were 33 (2-79) and 21 (8-68) months respectively. Three patients died during follow -up from unrelated causes. There were no graft complications or re-infection; at last follow up 2 grafts were not completely incorporated with no signs of infection. Conclusions: Operative management of aortic infection with involvement of the pararenal/paravisceral segment is complex. Though early mortality and morbidity are high in these sick patients, results in survivors are excellent with no long term sequelae and low risk of reinfection.
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