Treatment Strategies and Outcomes of Infected Thoracoabdominal and Pararenal Aortic Aneurysms
Javairiah Fatima, MD, Erik Anderson, MD, Jeffrey D. Crawford, MD, Michol A. Cooper MD, Salvatore T. Scali, MD, Martin R. Back, MD, MD, Kristina A. Giles, MD, Scott A. Berceli, MD, PhD, Dean K. Arnaoutakis, MD, Gilbert J. Upchurch, MD, Thomas S. Huber, MD, PhD
Objectives: Mycotic thoracoabdominal and pararenal aortic aneurysms (mTAAA/PRAA) or infections of TAAA and PRAA grafts (iTAAA/PRAA) are a rare but devastating clinical problem. Treatment requires complex surgical reconstruction to maintain visceral and renal perfusion. There is a paucity of literature describing outcomes for this technically challenging and highly lethal problem. Herein, we report our experience in the management of these patients. Methods: Retrospective review was performed for all patients undergoing surgical intervention for mTAAA/iTAAA between 2004-2017. The primary end-point was in-hospital mortality. Secondary end-points included in-hospital complications, re-intervention and re-infection. Results: Thirty-five patients underwent surgical intervention for mTAAA/iTAAA [mean age-62 years; male 83%]. Twenty patients had mTAAA (70%)/iTAAA (30%; all endografts) and 15 patients had mPRAA (33%)/iPRAA (67%; 60% endografts). Index operation was performed at a referring institution in 88%. Median time from index operation to presentation was 9 months (range 1-156months). Presentation was urgent/emergent for all but one patient, with rupture in 50%. An organism was identified from blood/operative cultures in 24 patients (88% monomicrobial, 12% polymicrobial); most commonly S. Aureus (46%), enterococcus (13%), and candida (13%). Surgical management included graft explant or excision with either in-situ rifampin-soaked graft with visceral artery bypass (66%), open visceral debranching followed by TEVAR (9%), aortic allograft with visceral artery re-implantation (9%), extra-anatomic bypass with oversewing of aortic stump and antegrade visceral artery bypass (9%), fenestrated EVAR (3%), or neoaortoiliac system using femoral veins with sacrifice of renal arteries (3%). One death occurred intraoperatively (3%). Major complications included acute renal failure requiring hemodialysis (22%), myocardial infarction (14%), spinal cord ischemia (6%), hemorrhage requiring re-exploration (6%), bowel ischemia requiring resection (3%), seroma evacuation (3%), and chyle leak (3%). Median length of hospital stay was 19 (range 1-92) days. Reinterventions included graft thrombosis (6%), anastomotic stenosis (6%), aortogastric fistula (3%), surgical site infection (3%), and mycotic aneurysm recurrence requiring visceral aneurysm repair (3%). In-hospital and/or 30-day mortality was 17%. At median follow-up of 1 month (range 0-69months) 60% are alive, with 20% requiring reinterventions and 6% re-infections. Conclusions: This is the largest series of surgical intervention for (mTAAA/PRAA) and iTAAA/PRAA. They frequently present as ruptures, requiring complex reconstruction with high 30-day mortality and complications. However, this strategy can be life-saving when performed in high-volume aortic centers with minimal long-term complications.
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