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The infected aorta
L K von Segesser1, P Vogt, M Genoni
1Clinics for Cardio-vascular Surgery, University Hospitals, Lausanne, Switzerland.
Background:
Despite the improvements achieved in antibiotic therapy, severe aortic infection resulting in mycotic aneurysms is still a highly lethal disease and surgical management remains a challenging task.
Patients And Methods:
A total of 43 patients with severe aortic infections were analyzed and separated in four groups: (1) Infections of the aortic root Ventriculo-aortic disconnection due to deep aortic infection (6 patients). Two patients were operated using homo-composit grafts. Of the 6 patients total, one died early and two died late during a mean follow-up of 6 years. The two patients with homografts are still alive. (2) Infections of the ascending aorta and the aortic arch. In situ repair for mycotic aneurysmal lesions of the ascending aorta was performed in 6 patients using synthetic graft material in 4/6, biological material in 1/6 and direct suture in 1/6. Two patients had to be reoperated; one of them died early. There was no recurrent infection during a mean follow-up of 6 years. (3) Infections of the descending thoracic and thoraco-abdominal aorta in-situ repair for mycotic aneurysmal lesions of the descending and thoraco-abdominal aorta was performed in 12 patients using homografts in five. Two patients died early and two other patients died late during a mean follow-up of 6 years. (4) Infections of the infrarenal abdominal aorta. In this series of 19 patients with mycotic infrarenal aortic aneurysms, in situ reconstruction was performed in 12 (5/12 with homografts) and extra-anatomic reconstruction (axillo-femoral bypass) was performed in 7. Hospital mortality was 5/19 patients and another 5/19 patients died during a mean follow-up of 6 years. One of the early deaths was due to aortic stump rupture. Two patients with axillo-femoral reconstructions were later converted to descending-thoracic-aortic-bifemoral bypasses. Five thromboses of axillo-femoral bypasses were observed in three of the seven patients with extra-anatomic repairs.
Results:
Infections of the aortic root, the ascending aorta and the aortic arch are approached with total cardio-pulmonary bypass, using cardioplegic myocardial protection and deep hypothermia with circulatory arrest if necessary. Proximal unloading and distal support using partial cardiopulmonary bypass is preferred for repair of infected descending and thoracoabdominal aortic lesions, whereas no such adjuncts are required for repair of infected infrarenal aortic lesions.
Conclusions:
The anatomical location of the aortic infection and the availability of homologous graft material are the main factors determining the surgical strategy.
Insights
Severe aortic infections, including mycotic aneurysms, remain lethal. Surgical strategies for aortic infections depend on infection location and graft availability, with varied outcomes across different aortic segments.
Area of Science:
- Cardiovascular Surgery
- Infectious Diseases
- Vascular Surgery
Background:
- Severe aortic infections leading to mycotic aneurysms present a high mortality rate.
- Surgical management of these infections is complex and challenging.
- Despite advances in antibiotic therapy, outcomes remain poor.
Purpose of the Study:
- To analyze surgical outcomes for severe aortic infections based on anatomical location.
- To evaluate the effectiveness of different surgical techniques and graft materials.
- To identify factors influencing patient survival and recurrence rates.
Main Methods:
- Retrospective analysis of 43 patients with severe aortic infections.
- Categorization into four groups based on infection location: aortic root, ascending aorta/arch, descending/thoraco-abdominal aorta, and infrarenal aorta.
- Surgical interventions included in situ repair with synthetic or biological grafts, homografts, direct suture, and extra-anatomic bypass.
Main Results:
- Outcomes varied significantly by anatomical location and surgical approach.
- Aortic root infections had high early and late mortality, with homografts showing promise.
- Descending and thoraco-abdominal aorta repairs utilized cardiopulmonary bypass adjuncts, while infrarenal repairs did not require them.
- Extra-anatomic bypasses for infrarenal infections showed high rates of thrombosis.
Conclusions:
- The anatomical site of the aortic infection is a critical determinant of surgical strategy.
- The availability of homologous graft material significantly influences treatment decisions.
- Tailoring surgical approaches to specific aortic segments and graft availability is essential for improving outcomes.