A Comparison Of Surgical Techniques And Outcomes For Primary Mycotic Aortic Aneurysms
Dana B. Semaan, MD, Salim G. Habib, MD, Michael C. Madigan, MD, Raymond Eid, MD, Michael J. Singh, MD, Rabih A. Chaer, MD MS, Michel S. Makaroun, MD, Mohammad H. Eslami, MD MPH.
University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
OBJECTIVES: Mycotic abdominal aortic aneurysms (MAAA) are associated with high morbidity and mortality. Three repair approaches include: open in-situ (OIR), extra-anatomic (EAR), and endovascular (EVAR). This study is one of the largest single-center case series comparing the outcomes of the different surgical approaches for MAAA.
METHODS: In this retrospective cohort study, all patients who underwent repair of primary mycotic aneurysm from January 2000 to December 2021 were identified. Our cohort was divided between surgical approaches. Primary outcomes included all-cause mortality at 1- and 5- years. Secondary outcomes were 30-day complications (cardiac, respiratory, renal, bowel, and adverse limb events) and 1-year reintervention-free survival. Appropriate statitistical methodologies were used to compared different surgical approaches.
RESULTS: A total of 43 patients were identified:16 EVAR, 14 EAR and 13 OIR. 53.4% of patients presented with a rupture, however there was no difference in presentation between the three groups All complications occurred within the first 30-days of the primary procedure. Neither 30-day mortality rates (23% EAR vs. 6.3% EVAR vs. 7.7% OIR; p=.28), 30-day postoperative complication rates (50% EAR vs. 19% EVAR vs. 15% OIR; p=.75), nor 1-year reintervention rates (EVAR 25%, EAR 36%, and OIR 38%; p=0.78) were significantly different between the groups. Overall mortality within 1- and 5-years were 25.6% and 37.2% respectively. Aneurysm related death accounted for 30% of all deaths. Although all-cause mortality rates were similar at 1-year, OIR patients had lower mortality than EVAR and EAR patients at 5 years (8% vs. 50% vs. 50% respectively, p=0.03) (Figure 1). Adjusted multivariable Cox regression analysis confirmed the association between the EVAR and increased 5-year mortality (aHR 12.1, [95%CI 1.42-103.9], p-value=.02) and EAR approaches (aHR 15.1, [95%CI 1.59-143.3], p-value=.0.02) compared to the OIR approach. CONCLUSIONS: Repair of mycotic aortic aneurysm is associated with high complication and mortality rates regardless of approach. In our studied sample, OIR offered an improved long-term survival without benefits in terms of complication rates. EVAR should be considered as bridging stage between the urgent situation and eventual repair. 
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