Resection and replacement of thoracic aortic graft infections

J Thorac Cardiovasc Surg. 2021 Jul;162(1):1-8. doi: 10.1016/j.jtcvs.2019.10.196. Epub 2019 Nov 27.

Abstract

Objectives: Thoracic aortic graft infection (TAGI) presents a formidable challenge with high mortality. We evaluated our 22-year experience managing TAGI with extensive debridement, graft replacement, vascularized tissue coverage, and aggressive antibiotics.

Methods: We reviewed all consecutive patients with TAGI from 1991 to 2013. We also compared infected cases versus noninfected reoperative controls using a case-control design. Standard statistical methods were used for descriptive analysis, and Kaplan-Meier for survival analysis.

Results: We treated 32 TAGI patients, involving 19 ascending/arch (A/A) and 13 descending/thoracoabdominal (D/TAA) grafts, including 4 endografts. In total, 19 (59.4%) presented with pseudoaneurysm and 11 (34.4%) with aortic fistula. Vascularized tissue (omentum or muscle) coverage was possible in 22 (71.0%) patients. Thirty-day mortality occurred in 3 (9.4%) patients, with no 30-day mortality among those receiving vascularized graft coverage (P = .018). During follow-up, reinfection occurred in 8 patients (25% [4 A/A and 4 D/TAA]). Five-year overall (A/A 45.4% vs D/TAA 28.9%, P = .434) and reinfection-free (A/A 19.2%, D/TAA 27%, P = .409) survival was similar between groups. Long-term mortality was greater after endograft infection (100% vs 25% at 2.5 months, P = .0007) or aortobronchial fistulization (100% vs 37.9% at 6 months, P = .026). Time to reintervention was shorter in infected versus non-infected reoperative cases (31 vs 83 months, P < .0001), but there were no significant differences in long-term mortality after reoperation.

Conclusions: TAGI continues to represent a highly morbid surgical challenge. Prompt antimicrobial coverage, debridement, graft replacement, and vascularized graft coverage, yielded best long-term results. Endograft infection and aortobronchial fistula had very poor prognoses.

Keywords: aortic aneurysms; aortic graft infection; descending thoracic aortic repair; endograft infection; infection; thoracic aortic graft infection; thoracoabdominal aortic repair.

Publication types

  • Video-Audio Media

MeSH terms

  • Adult
  • Aged
  • Anti-Bacterial Agents / therapeutic use*
  • Aorta, Thoracic / surgery*
  • Aortic Aneurysm, Thoracic / surgery
  • Blood Vessel Prosthesis / adverse effects*
  • Blood Vessel Prosthesis Implantation / instrumentation*
  • Blood Vessel Prosthesis Implantation / methods
  • Case-Control Studies
  • Combined Modality Therapy
  • Debridement / methods*
  • Female
  • Gram-Negative Bacterial Infections / mortality
  • Gram-Negative Bacterial Infections / therapy
  • Gram-Positive Bacterial Infections / mortality
  • Gram-Positive Bacterial Infections / therapy
  • Humans
  • Kaplan-Meier Estimate
  • Male
  • Middle Aged
  • Mycoses / mortality
  • Mycoses / therapy
  • Prosthesis-Related Infections / mortality
  • Prosthesis-Related Infections / therapy*
  • Reoperation / instrumentation
  • Reoperation / methods*
  • Retrospective Studies
  • Treatment Outcome

Substances

  • Anti-Bacterial Agents