Surgical strategy for aorta-related infection†

Abstract

Objectives: This report describes our experience with surgical management of aorta-related infections.

Methods: From November 1999 to April 2013, 70 patients underwent surgical management for aorta-related infection, including aortobronchial fistula in 12 patients, aorto-oesophageal fistula in 14 and aortoduodenal fistula in 4. The location of infection was aortic root to arch in 22 patients, descending aorta in 29, thoraco-abdominal aorta in 12 and abdominal aorta in 7. Forty-seven patients had infections of the native aorta and 23 had postoperative graft infections. In situ replacement [bridge thoracic endovascular aortic repair (TEVAR); n = 1] was performed in 45 patients, endovascular aortic repair in 18 and extra-anatomical bypass (bridge TEVAR; n = 2) in 7. Omental flap was installed in 29 patients and a pedicled latissimus dorsi muscle flap was used in 3. Since 2008, we have been trying to resect not only the infected tissues, but also the surrounding aneurysmal wall as well.

Results: Hospital mortality was 17.1% (12/70). Late death occurred in 15 patients. Overall survival at 3 years was 60.1 ± 6.7%. Freedom from infection-related death of patients who had in situ graft replacement, endovascular repair or extra-anatomical bypass at 3 years was 88.5 ± 4.9, 75.2 ± 10.9 or 14.3 ± 13.2%, respectively (P < 0.01). In situ graft replacement provided a better freedom from aortic event (recurrent infection and reintervention) at 3 years compared with endovascular repair (85.6 ± 5.5 vs 61.8 ± 12.5%, P = 0.029). Freedom from infection-related death at 3 years improved significantly from 61.1 ± 9.7 (before 2008) to 84.7 ± 5.8% (since 2008) (P = 0.044).

Conclusions: Surgical treatment for aorta-related infection is still associated with high mortality and morbidity. However, our current strategy, which is aggressive surgical management, including resection of infected tissues, extensive debridement, in situ graft replacement of the aorta and omental or muscle installation provided a better patient survival.

Keywords: Aortic infection; Endovascular repair; Extra-anatomical bypass; In situ graft replacement; Muscle flap; Omental flap.