A multicenter experience with the surgical treatment of infected abdominal aortic endografts.

OBJECTIVE: Single-center experiences with the treatment of infected endografts after endovascular aortic repair (I-EVAR) have been reported. We performed a multicenter review of the surgical care of these patients to elucidate short-term and long-term outcomes.

METHODS: A retrospective analysis of all EVAR explants from 1997 to 2014 at four institutions was performed. Patients with I-EVAR undergoing surgical treatment were reviewed. Data were obtained detailing preoperative demographics, and postoperative morbidity and mortality.

RESULTS: Thirty-six patients (30 male) were treated with endovascular graft excision and revascularization for I-EVAR with a median age of 69 years (range, 54-80 years). Average time from the initial EVAR to presentation was 589 days (range, 43-2466 days). Preoperative comorbidities included hypertension, 32 (89%); tobacco use, 31(86%); coronary artery disease, 26 (72%); hyperlipidemia, 25 (69%), peripheral artery disease, 13 (36%); cerebrovascular disease, 10 (28%); diabetes, 10 (28%); chronic obstructive pulmonary disease, 9 (25%); and chronic kidney disease, 9 (25%). The most common presenting patient characteristics were leukocytosis, 23 (63%); pain, 21 (58%); and fever, 20 (56%), which were present an average of 65 days (range, 0-514 days) before explantation. Nine different types of endograft were removed. Three patients (8%) underwent emergency explantation. Thirty-four patients (89%) underwent total graft excision, and two patients (6%) underwent partial excision. Methods of reconstruction were in situ in 27 (75%) and extra-anatomic in nine (28%). Conduits used were Dacron (DuPont, Wilmington, Del), with or without rifampin, polytetrafluoroethylene, cryopreserved allograft, and femoral vein. Forty-nine organisms grew from operative cultures. Gram-positive organisms were the most common, found in 24 (67%), including Staphylococcus in 13 (36%) and Streptococcus in six (17%). Anaerobes were cultured in 6 patients (17%), gram-negative organisms in 6 (17%), and fungus in 5 (14%). Thirty-one patients (86%) received long-term antibiotics. Early complications included acute renal failure requiring dialysis, 12 (33%); respiratory failure, 3 (8%); bleeding, 4 (11%); and sepsis, 2 (6%). Six patients required re-exploration due to hematoma, infected hematoma, lymphatic leak, bowel perforation, open abdomen at initial operation, and anastomotic bleeding. Perioperative mortality was 8% (3 of 36), and long-term mortality was 25% (9 of 36) at a mean follow-up of 569 days (range, 0-3079 days). Type of reconstruction (in situ vs extra-anatomic) or conduit type did not affect perioperative or overall mortality.

CONCLUSIONS: I-EVAR is a rare but potentially devastating clinical problem. Although perioperative mortality is acceptable, long-term mortality is high. The most common postoperative complication was acute renal failure requiring dialysis. Although this is the largest series of I-EVAR, further studies are needed to understand the risk factors and preventive measures.