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A Single Center Experience With Management Of Ruptured Native Aortic Infection
Madeline Drake, MD, Shashank Sharma, MD, Jacob B. Watson, MD, Jose S. Montelongo, MD, Kaled Diab, MD, Dalila White, MD, Maham Rahimi, MD.
Houston Methodist Hospital, Houston, TX, USA.
OBJECTIVES:Ruptured native aortic infection (RNAI) without aneurysmal degeneration is rare with no consensus on timing and steps of surgical management. The aim of our study was to report our recent experience with RNAI and our primarily staged surgical approach.
METHODS:From January 2021 to May 2023, 7 patients with RNAI presented to our institution. The diagnosis was based on: clinical presentation, laboratory, intraoperative and imaging findings. The primary endpoint was 30-day mortality, and the secondary endpoints were in-hospital mortality, graft patency, and freedom from reinfection.
RESULTS:The mean age was 65 (range 58 to 82) with disease at the level of thoracoabdominal (TAA) (n = 1), supra-renal (n = 1) and infra-renal (n=5) aorta. All patients had atherosclerotic plaque at rupture sites with unique comorbidities that would explain bacterial seeding from remote/adjacent origins: end stage renal disease; orthotopic heart transplant on immunosuppression with psoas/hepatic abscesses; T-11 osteomyelitis; recurrent urinary tract infections; and occupational hazard. Preoperative leukocytosis/fevers were found in 3 patients (60%). All patients had positive blood cultures. Patient 1 presented with contained, supra-celiac aortic rupture and underwent aortic cuff stent graft placement with plans for elective explantation after a period of intravenous antibiotics. Patient 2 presented with contained aortic rupture at the level of the superior mesenteric artery and underwent open TAAA repair with partial left heart bypass. Patients 3, 4 and 5 presented with contained rupture of the infra-renal aorta and underwent open aortobiliac repairs with rifampin-soaked Dacron grafts. The grafts were sewn in-situ and the abdomen was irrigated with antibiotics and closed temporarily. They returned the following day for further irrigation, flap coverage and abdominal closure. Patients 6 and 7 presented to an outside hospital with RNAI and hemodynamic instability and underwent EVAR. Upon transfer to us, they had infected EVAR/native aorta and underwent explantation with staged aortobiliac repair, as previously described. No mortality has occurred in 30-days and mid-term follow-up. The grafts' patency and freedom from reinfection were 100%.
CONCLUSIONS: The optimal management of RNAI is unknown. We demonstrate no short- to mid- term mortality or reinfection with our staged surgical approach, when possible, with endovascular salvage and abscess drainage followed by definitive treatment. A consensus on RNAI definition and management is needed with the help of multi-institutional studies.
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