Secondary infections of thoracic and abdominal aortic endografts

To review several cases of stent-graft infection with respective outcomes to identify clinical presentations and responses to treatment options.

The authors performed a single-center retrospective review of all secondary endograft infections from January 2000 to June 2007. Infections were identified from an institutional database containing all abdominal and thoracic endovascular aneurysm repairs (EVAR and TEVAR) performed at the treating hospital.

From January 2000 to June 2007, 389 EVAR and 105 TEVAR were performed at the treating hospital. Ten endograft infections were identified (five EVAR and five TEVAR). Four infections occurred in grafts placed at outside institutions and six in grafts placed in-house. The in-house prevalence of EVAR and TEVAR infection is 0.26% and 4.77%, respectively. None were placed for a presumed pre-existing mycotic aneurysm. The mean time from the index procedure to the diagnosis of infection was 243.6 days +/- 74.5. Two patients who underwent EVAR presented with a contained rupture, and the remaining eight patients presented with constitutional symptoms and/or abscess formation on imaging studies. Microbiology cultures revealed Propionibacterium species (n = 3), Staphylcoccus species (n = 3), Streptococcus species (n = 2), and Enterobacter cloacae (n = 1). All EVAR patients underwent removal of the infected endograft and reconstruction with extraanatomic bypass (n = 3) or in situ homograft placement (n = 2). During a mean follow-up of more than 1 year, there were no recognized complications or recurrence of infection. Only one of the five TEVAR patients underwent removal and interposition grafting with an antibiotic-impregnated Dacron graft. The remaining four patients were medically managed--one patient survived and was placed in hospice care, two died of mycotic aneurysm rupture, and one died from multiorgan system failure secondary to sepsis.

Graft-related septic complications following EVAR or TEVAR are rare but associated with significant mortality. Several surgical treatment options are available, each potentially equally successful. The effect of prophylactic antibiotic use during subsequent invasive procedures must be solidified.