Two-Decade Single-Center Experience with Graft Infections After Infrarenal Endovascular Aortic Repair

To study the incidence of endovascular aneurysm repair (EVAR) graft infections and to examine the results of treatment at a single institution, where the mainstay of treatment has for 20 years been to explant the infected grafts and to reconstruct in situ with biological materials.

All standard EVAR patients treated from January 2000 to December 2022 at our institution were extracted from a prospective vascular surgery database, and post-EVAR infections were identified through a chart review and analyzed retrospectively. Primary endpoints were short-term (30-day and 90-day) mortality and mid-term survival. Secondary endpoints were freedom from reinfections and freedom from reinterventions.

A total of 29 EVAR grafts in 1,274 patients became infected during a mean total follow-up of 6.36 years (range 4.4 months-23.3 years). The cumulative rate of infections was 1.7%, and the incidence rate was 2.69 cases per 1,000 patient-years in the patient group where the primary EVAR was performed in an elective setting. The median time to infection was 8.4 months (range: 9 days-11.4 years). With 3 additional patients from other institutions, a total of 32 patients underwent treatment for an EVAR graft infection. Only 2 patients (6.3%) were female. Nine patients (28.1%) were treated conservatively, 1 patient was operated with a graft preservation strategy and the rest (n = 22, 69%) underwent graft explantation and in situ reconstruction. In these 22 reconstructions, the graft material used was an autologous femoral vein in 19 (86.4%) patients, a cryopreserved allogenous femoral vein in 2 (9.1%) patients, and a rifampicin-soaked dacron prosthesis in 1 (4.5%) patient. The early postoperative mortality was 19.0% (n = 4 of 21) at 30 days and 23.8% (n = 5 of 21) at 90 days for the patients with explanted grafts with in-situ reconstruction, while survival at 1 year was 76.2% (n = 16 of 21) for the group treated with biological reconstruction and 44.4% (n = 4 of 9) for the conservatively treated patients. Similarly, in Kaplan-Meier analysis, the 3-year survival was 68.2% and 22.2%, respectively (P = 0.002). During a median follow-up of 2.3 years (range: 3 days-12.4 years), there were no reinfections among patients with biological reconstructions, and none of the patients required late graft reinterventions.

EVAR graft explantation and in situ biological aortic reconstruction offers a viable, infection-resistant and durable solution for the treatment of EVAR infection.