Abstract:
OBJECTIVES:Graft infection is a serious consequence of aortic surgery, yet its
treatment remains a debated topic in the literature. We sought to analyze our
outcomes for aortic graft infections over the last 12 years.
METHODS: This is a retrospective cohort study of all patients treated at the
University of Maryland Medical Center with aortic graft infections over the last
12 years.
RESULTS: Between 2000 and June of 2013, 26 patients were treated for
infected aortic grafts. Mean age was 70.9 years, with males comprising 65.3%
of patients. Twenty-two grafts (84.6%) were aortobifemoral/unifemoral/iliac, 2(15.4%) open aneurysm repairs, 1 (3.8%) EVAR
and 1 aorto-mesenteric bypass. All patients underwent an operative
procedure. 30-day mortality was 19.2%. Presentation was lower GI bleeding
in 5(19.2%); systemic sepsis in 13(50%); distal anastomotic leak in 2(7.7%)
and two presented with a thrombosed graft. Perigraft (CT) findings were seen
in patients with LGIB (fistula) and systemic infection or thrombosed grafts
(gas/fluid). Extravasation of contrast was seen in CT’s in all patients with
anastomotic leak. There were no preoperative independent predictors of
mortality. Five (19%) patients had infections involving the main body of the
graft. Extra anatomic bypass was required in 19(73%) of the patients, with
12(46%) undergoing resection of the infected graft at the same setting. PTFE
15(65%) was the reconstruction conduit of choice. 18(69%) of patients were
treated with a partial graft resection and 8 (31%) required complete removal
of the infected graft. Six (23%) patients required amputations, all of which
had aorto-bifemoral bypasses as the original operation. 15(58%) of patients
required multiple vascular operations. An organism was cultured in 100% of
cases (blood or tissue). There was no association between organism and
death. Multiple organisms were recovered in 12(46%) patients.
Staphylococcus (MRSA/MSSA), candida, GNR’s, enterococcus and bacteroides
were the most common organisms, in order of frequency. Six (23%) patients
developed renal failure, half of which died. 11(42.3%) of patients developed
respiratory failure. Five (19%) patients died in the follow-up period, none
related to their aortic infection. There were no late aortic stump blowouts.
CONCLUSIONS:Aortic graft infection remains a significant clinical problem
with amputation or death as a common outcome. Complete resection of the
infected graft is not necessary for long-term survival. Extra anatomic bypass is
a safe and reliable reconstructive option.