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C. M. Wittgen et al.
Fig. 17.4 Diagram of NAIS reconstruction with aorto-profunda femo-
ris and aorto-external iliac anastomoses. (Drawing courtesy of Ahsan
Ali MD)
reported to be extremely low with only 12% of patients
requiring fasciotomy and 15% experiencing long-term venous
insufciency [56]. In a more recent series of 56 severely ill
patients where 21 had aortoenteric stulae as the presenting
symptom, 30-day mortality was 13% with seven subsequent
anastomotic ruptures from reinfection and a 4% major amputation rate. Primary graft patency rates remained high, and
5-year survival was 63% [58]. Risk factors identied in both
series for poor patient outcome with recurrent infection and
death included the presence of aortoenteric stula, positive
perioperative cultures, fungus identied as the infecting
organism, and the need for femoral anastomoses [56, 58].
The use of allografts in this setting has enormous appeal
with a decrease in patient morbidity when compared to extraanatomic reconstruction, an overall decrease in operative
time when compared to the NAIS procedure, and a theoretical resistance to infection when compared to synthetic grafts.
Additionally, large-sized grafts are available for more proximal aortic reconstruction just as with synthetic grafts.
Allografts were originally used in the 1950s, but results were
disappointing with rejection and late aneurysm formation
occurring frequently [59]. Currently, these grafts are cryopreserved within 24 h of harvest and selected to be ABO
compatible. Cryopreservation has been shown to maintain
structural integrity while decreasing antigenicity [
60, 61].
More recently, however, it has been noted that some immunogenic properties of the vessel are maintained in the
allograft [62]. Differing degrees of rejection reaction have
been postulated to occur long term, and the necessity for
ABO and HLA matching is no longer certain [61, 63].
Multiple case reports have documented reasonable operative times with acceptable perioperative morbidity and mortality (6%) throughout the 1990s with use of these grafts
[64]. Distinct technical challenges were recognized as more
experience was gained. The thawing procedure for these
grafts is somewhat lengthy (30–60min) but maintains durability and should be timed accordingly for graft availability
during the procedure. Rapid thawing or mechanically removing ice from the material increases the risk of micro-fracture
of cryopreserved material. Additionally, these grafts should
not be clamped for the same reason. If absolutely necessary,
the portion of the graft that will later be excised is recommended as a clamp site. Consideration of the angle of the
iliac limbs and performance of a tension-free anastomosis
are important factors to maintain long-term patency and to
avoid anastomotic aneurysms. Side branches should be carefully searched for and suture ligated since late blow out or
erosion into surrounding viscera has been reported. Use of
an allograft does not eliminate the need for aggressive
debridement or drainage of the area. Aggressive, difcult-totreat infections may require prolonged intravenous therapy
for up to 3months, but use of an allograft does not appear to
increase the risk of complications. With these factors recognized, 30-day mortality has decreased to 2.6% in one series
[65]. These results have been conrmed in more recent series
(8%), and more data is being accumulated on long-term
complications. In a retrospective review of 25 patients treated
over a 10-year interval, late mortality occurred in 20% with
graft complications occurring in 12%. These included one
case of thrombotic occlusion of the graft, one aneurysmal
degeneration, and one case of aortoenteric stula. Seventyfour percent of patients survived 3years in this series with an
event-free survival of 58% [63]. It has been observed that in
series with more patients with aortoenteric stula, mortality
rates are higher (39%) [66]. Additional patient factors such
as the cause of infection (primary versus graft related),
co- existing comorbidities, type of organism, completeness
of debridement, anatomic location (thoracic versus visceral
segment versus infrarenal) and emergent nature of procedure
impact patient outcome as well. Observations gained from
multiple case reports and retrospective small series have
found that patients who tolerate this procedure with less
morbidity and risk of mortality are generally those younger
than age 65 with a native aortic infection in an infrarenal
position from a pan-sensitive gram-positive organism without obvious purulence at operation. A sufcient length of
17 Aortic Infection: Pathophysiology, Bacteriology, andManagement
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omentum to cover the new allograft and anatomy not requiring a femoral anastomosis also impact favorably on the outcome [63–69].
Given the risk to the patient and the complexity of the
procedures described, the appeal of endovascular options to
treat these aortic infections is apparent. In discussing current experience and recommendations, there are distinct
anatomic differences with many initially advocating TEVAR
as the treatment of choice for all ruptured mycotic thoracic
aneurysms and most of the intact ones [13]. One-year survival is 76% with this strategy [70]. Others have noted no
perioperative mortality and a 30% later conversion to an
open procedure in a small series of patients treated with
TEVAR which included a patient with aortoesophageal stula and one with an aortobronchial stula [71]. In contrast,
EVAR was more often seen as a bridge to denitive therapy
in patients with infrarenal aortic infection. A recent
European multicenter collaboration is the largest series of
123 patients studied. One-month survival was 91% with 5and 10-year survival rates of 76% and 66%, respectively
[13]. Twenty- seven percent of the patients included in this
study had an infectious complication with one-third occurring within the rst 30days and 82% by the end of the rst
year. Patients with non-Salmonella-positive blood cultures
were more likely to have late infectious complications associated with mortality. The authors noted that this compared
very favorably to the results obtained with the previously
described procedures especially considering that this
European series had a majority of patients with severe
comorbidities, hostile anatomy, ongoing sepsis, or rupture.
The current results also seem exceedingly positive when
compared to the large Swedish study of 946 patients undergoing routine elective EVAR for noninfected abdominal
aortic aneurysm where the 5-year survival rate was 65%
[72]. The authors also noted that even with this largest series
of patients, the mortality is indisputably low, but risk factor
analysis may be plagued by type II statistical error due to
the small sample size.
Postoperative Management andOutcome
After any of these types of procedures, patients are extremely
ill and most often requiring prolonged ICU stays. Little is
written in textbooks of vascular surgery about this important
phase of these patients’ care. Ventilatory support is often
required for at least the rst 24–48 h. While patients may
already be receiving intravenous broad-spectrum antibiotics,
often they appear septic perioperatively from the debridement of the infected tissue. In addition, there are further uid
shifts (“third spacing”) with prolonged clamp times during
aortic excision and reconstruction. As a result, patients
appear volume depleted with ongoing uid requirements.
They may appear tachycardic (heart rate>90), tachypneic
(>20 breaths/min or PaCO
< 32), febrile (core tempera-
2
ture>38°C), or hypothermic (core temperature<36°C) and
have either a high or low white blood cell count (>12 × 109/l
or <4 × 109/l) [73]. Key points in management during this
phase are in keeping with the Surviving Sepsis Guidelines
and include use of crystalloids for initial resuscitation, consideration for albumin use with large volume requirements,
norepinephrine for persistent hypotension despite adequate
volume resuscitation with the addition of epinephrine or
vasopressin as indicated, and consideration for systemic corticosteroids only for those patients who remain unstable
despite all of the above measures [74]. Abdominal compartment syndrome should be checked for with ongoing resuscitation by measurement of bladder pressures through the
Foley catheter [75, 76] and lower extremity compartment
syndrome considered in patients after a NAIS procedure.
Debrided infected material should be sent from the operating room for gram stain and culture (including fungal)
regardless of the presence of positive blood cultures.
Antibiotic therapy should be directed based on culture results
and appropriate follow-up arranged with infectious disease
specialists for monitoring drug levels and side effects. Most
recommend a minimum of 6weeks of intravenous antibiotics [77]. Frequent physical examinations with white blood
cell count, sedimentation rate, and C-reactive protein levels
are frequently checked during this period to monitor for
signs of worsening infection, poor response to therapy, or
abscess. The role of suppressive antibiotics after this treatment is debated. Because of the concerns of recurrent infection in the space on in newly place graft material in difcult
to access areas, most recommend lifelong antibiotics [23, 38,
51, 63]. The role of routine postoperative radiologic imaging
is also debated since early postoperative images (within the
rst month) will undoubtedly have retained uid and gas at
the site of infection. Once a patient is beyond the immediate
postoperative period, the role for routine imaging becomes
even less clear since few would advocate surgical intervention
in an asymptomatic patient who had already received a denitive high-risk procedure to address the infection.
Complications from primary aortic infections can present
at time of diagnosis as aneurysmal degeneration, septic
emboli, or thrombosis or can occur as a result of treatment.
Subsequent graft thrombosis can also occur acutely as a
result of these processes or occur late with the highest incidence occurring in those patients with extra-anatomic reconstructions. Limb loss is not infrequent in these patients with
some series reporting subsequent amputation rates greater
than 20% [78]. Abscesses in adjacent structures such as the
psoas muscle and vertebral body can further complicate
management and mandate further debridement [79].
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Recommendations
The AHA has published guidelines on the best operative
strategies for patients with these complex infections [80].
The involvement of experts in radiology, cardiology, infectious disease, and vascular surgery is key to management.
Antibiotics are recommended for a minimum of 6weeks and
as long as 6 months in select cases. Lifelong suppression
should also be considered for patients who have prohibitive
operative risk for a repeat intervention or for those with
extensive or aggressive infection. Antibiotics alone are recommended only for those patients are not t for surgery or
who refuse intervention. For the majority of patients, excision of the infected aneurysm and surrounding tissue is the
treatment of choice with in situ revascularization. Extraanatomic reconstruction as part of a staged management
strategy is recommended for those with gross purulence in
the operative led, retroperitoneal or psoas abscess, adjacent
vertebral osteomyelitis, inadequate response to preoperative
antibiotics, or in cases of aortoenteric stula. Endovascular
management may be considered as a bridge to denitive
therapy for ruptured infected aneurysms, cases of aortoenteric stula, or for those who are unt for open procedures.
This strategy allows for later removal of the endograft, excision of surrounding infected material, and reconstruction
when the patient has been stabilized.
Aortic Graft Infections
Incidence andRisk Factors
Literature on infections of the aorta needs to be reviewed
closely since many series discuss primary aortic infections in
conjunction with aortic graft infections when discussing
operative results and long-term outcomes. Graft infections
are a distinct separate entity with a reported incidence of
0.5–2% [81]. In a large retrospective study of 12,626 patients
with abdominal aortic aneurysm surgery from 1987 to 2005,
the 2-year incidence of graft infection was extremely low at
0.19% [82]. Others have noted an incidence as high as 6%
with groin incisions [39, 83–87]. Factors identied making
patients susceptible to graft infection were surgical site
infections and episodes of bacteremia during the index hospitalization. Other risk factors include recent hospitalization,
MRSA colonization, failed arterial reconstruction, femoral
anastomosis, and history of smoking and diabetes mellitus.
With CDC and NSQIP data documenting skin and supercial surgical site infections for aorto-bifemoral bypass surgeries as high as 10–15%, long-term follow-up with a high
index of suspicion is needed [88]. Aortic endografts are also
not immune to infectious complications with a reported inci-
dence of 0.5–0.7% [
ous concern even in this era of modern antibiotics.
89]. Aortic graft infections remain a seri-
Classication
Aortic graft infections are characteristically categorized
based on time of graft implantation and severity of infection.
Early graft infections occur within 4months and late graft
infections occur after 4 months of graft implantation. The
oldest classication is the Szilagyi classication of graft
infections, outlined in 1972. Grade I is phlegmon, grade II is
subcutaneous tissue infection, and grade III is graft infection. Samson’s classication is very similar and also clinically relevant: class I is supercial infection involving the
skin and/or subcutaneous tissue but no deeper than the dermis, class II is deep incisional infection involving deep soft
tissues such as fascia and muscles but without involvement
of the graft, class III is infection of the graft but without
anastomotic site involvement, class IV is infection with
anastomotic involvement, and class V is infection with anastomotic disruption and/or sepsis [90–92].
Bacteriology
While several factors exist that increase the risk of a graft
infection, the majority of graft infections are the result of
contamination during surgery at the time of implantation.
Additional risk factors to consider include wound healing
capabilities of the patient which are affected by medical
comorbidities such as diabetes mellitus, obesity, and malnutrition, as well as use of immunosuppressive medications.
End-stage renal disease is a well-known risk factor for graft
infection as uremia acts to depress the immune system and
dialysis patients are more commonly colonized with
methicillin- resistant Staphylococcus aureus [89]. Elective
placement of an aortic graft is by denition a clean procedure with an expected infection rate of <3% predicted by the
CDC [93]. Placement of a foreign material (aortic graft) provides an environment for bacterial adhesion and biolm.
Intraoperative factors including hypothermia, hypotension,
excessive blood loss, hypoxia, simultaneous infections of
extremities, prolonged procedures, concomitant additional
procedures, and emergent procedures are all common with
extensive aortic surgery and have also been associated with
increased risk of infection [94, 95]. Surgical incisions with
extensive dissection in poorly perfused areas during arterial
clamping combined with lymphatic disruption and later
hematoma formation are also common with aortic surgery
and provide an ideal environment for the development of
infections.
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Unlike primary aortic infections, the vast majority of aortic graft infections are gram positive. While important to
obtain, blood cultures are still negative in 25–50% of patients
[96]. The most common microorganisms cultured from aortic graft infections are Staphylococcus aureus (30–36%) and
coagulase-negative Staphylococcus species (21–47%) [96,
97]. Methicillin-resistant Staphylococcus aureus has been
reported in some series as being the most prevalent at 75%
[98]. Other series, with high numbers of aortoenteric stula
at presentation, have found greater numbers of gram- negative
and anaerobic infections (46%) [99]. Pseudomonas infections are most commonly associated with graft disruption
and hemorrhage [95]. Proteus species are also highly virulent, secreting potent proteases that cause tissue disruption
and can result in dramatic clinical manifestations such as
anastomotic disruption and frank hemorrhage. Laboratory
markers such as white blood cell counts and ESR and CRP
levels are frequently elevated but are neither sensitive nor
specic for aortic graft infection. Late infections (>1month)
with no history of prior wound infection are more often
Staphylococcus epidermidis and are most frequently indolent infections [45].
Presentation
Similar to primary aortic infections, aortic graft infections
can present as acute or chronic. Early graft infections present
more commonly with systemic signs of infection with high
fever, sepsis, abdominal and back pain, and leukocytosis.
They are more commonly caused by highly virulent organisms. These are the infections most commonly associated
with groin-related complications such as hematoma, seroma,
and incisional dehiscence with subsequent soft tissue infection. Late graft infections tend to be more subtle with less
systemic symptoms, generalized malaise, weakness, weight
loss, and often lack a febrile response. Infrainguinal infections presenting as cellulitis, soft tissue infection, draining
sinus tracts, or pseudoaneurysm can alert the clinician to a
possible graft infection. Intraabdominal graft infections can
present more dramatically as overwhelming sepsis or herald
gastrointestinal bleeding or appear to be very nonspecic
with symptoms of ileus and abdominal distention with or
without abdominal tenderness [95].
Diagnosis
A complete assessment of the graft and adjacent anatomy is
achieved with CT imaging. The evidence of infection on imaging may range from subtle signs of perigraft inammation to
large perigraft inammatory masses with adjacent gas. CT diag-
nostic criteria for graft infection include perigraft uid, perigraft
soft-tissue attenuation, perigraft gas, pseudoaneurysm, and
focal bowel wall thickening. The challenge in imaging-based
diagnosis is the timing from graft implantation as perigraft uid
and gas may be visualized in the postoperative period for up to
1week in patients without infection. These same ndings are
considered abnormal, however, and diagnostic of graft infection
when present 4–7weeks postoperatively [
Other radiologic modalities can be used to detect aortic
graft infection. Duplex ultrasound (DUS) is noninvasive,
more cost effective, but highly operator dependent, and its
usefulness may be limited by anatomic location. DUS is
most useful for infrainguinal evaluation and diagnosis of
pseudoaneurysm, peri-prosthetic air, or uid collections and
can distinguish hematoma from abscess [95]. For Central
aortic graft infection, the diagnostic ability is very limited
with DUS due to overlying bowel gas and body habitus of
patients. The sensitivity and specicity is thus quite low, and
DUS is not as useful for denitive diagnosis of aortic graft
infections [
pher as CT imaging in the early postoperative period but is
superior, however, in differentiating small perigraft uid collections from inammatory changes. As is seen in primary
aortic infections, a low-density signal on T1 images and
hyperintense signal on T2 images is consistent with infection. MRI has the advantage of being noninvasive with comparable sensitivity and specicity rates as CT in diagnosis
[102, 103]. FDG- PET- CT is based on metabolically active
cells’ uptake of radioactive-labeled glucose. This imaging
method can detect even subtle graft infections and document
the extent. A focal uptake of FGD can be observed in 93% of
graft infections, and in the absence of uptake, infection may
be able to be excluded in 97% of cases [104]. Indium white
blood cell scanning can provide useful information as to the
extent of graft infection [105]. Suspicions of aortic enteric
stula should be evaluated with careful endoscopy in a setting prepared for immediate exploration and repair of the
stula. In the largest series of aortic graft infections, the
majority of these patients were diagnosed based on signs of
systemic infection including fever, chills, or septic shock or
signs of infection including elevated white blood cell count
or C-reactive protein. Radiologic ndings were more obvious than with primary aortic infections and include air, uid,
or abscess around the graft [99]. In an attempt to establish
evidence- based guidelines, a set of major and minor criteria
has been established to diagnose aortic graft infections.
Aortic graft infection is suspected in a patient with any isolated major criterion or minor criteria from two of the three
categories: clinical/surgical, radiological, or laboratory.
Aortic graft infection is diagnosed in the presence of a single
major criterion, plus any other criterion (major or minor)
from another category [106] (see MAGIC table Fig.17.5).
101]. MRI can be equally as challenging to deci-
100].
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Fig. 17.5 Criterion for
diagnosis of aortic graft
infection. (From: Lyons etal.
106]. Reprinted with
[
permission from Elsevier)
Major criteriaMinor criteria
Clinical / SurgicalRadiology Laboratory
• Pus (confirmed by
microscopy) around graft or
in aneurysm sac at surgery
• Open wound with exposed
graft or communicating sinus
• Fistula development e.g.
aorta-enteric or aorto bronchial
• Graft insertion in an infected
site e.g. fistula, mycotic
aneurysm or infected
pseudoaneurysm
• Localized clinical features of
AGI e.g. erythema, warmth,
swelling, purulent discharge,
pain
• Fever ≥38°C with AGI as
most likely cause
Endograft Infections
While less invasive, aortic stent graft infections do occur
despite the increasing number being performed percutaneously. Previous reports have described an incidence of 0.43–
0.69% [107, 108]. A recent review of patients treated in
Ireland over an 8-year period documented an incidence of
graft-related sepsis occurring in 6 of 509 patients (433 elective and 76 emergent) [109]. The majority of the infections in
these series have presented within 2–5years after implantation [110]. The identied technical risk factors associated
with the development of subsequent graft infection included
subsequent interventions for endoleak, aortoenteric stula,
and systemic infections temporally related to the time of
graft implantation [107, 108]. Presentation of aortic endograft infections appears to have been slightly different as
well with one-third presenting with symptoms of chronic
infection, one-third with acute sepsis, and remaining onethird as aortoenteric stulae [107, 108, 111, 112].
Debate still exists as to which procedure, open or endovascular, poses less infectious risk to the patient. Proponents for
open procedures note the increased bacterial adherence and
less resistance to infection found with endografts [112, 113].
There is, however, good data documenting similar rates of
infection between the two procedures [82, 113]. Endovascular
proponents note the sterile delivery system, but those advantages may unfortunately be offset by the decreased sterility
noted in many radiology suites when compared to traditional
operating rooms [107]. All agree, however, that any type of
graft is subject to bacterial seeding and that determining the
cause of infection in many patients is difcult since most are
referred to tertiary care referral centers where the details of
their care may not be available [108].
• Peri-graft fluid on CT scan ≥ 3
months after insertion
• Peri-graft gas on CT scan ≥ 7
weeks after insertion
• Increase in peri-graft gas
volume demonstrated on serial
imaging
• Other e.g. suspicious peri-graft
gas/fluid/soft tissue
inflammation; aneurysm
expansion; pseudoaneurysm
formation; focal bowel wall
thickening; discitis/
osteomyelitis; suspicious
metabolic activity on FDG PET/
CT; radiolabelled leukocyte
uptake
• Organisms recovered from an
explanted graft
• Organisms recovered from an
intra-operative specimen
• Organisms recovered from a
percutaneous, radiologically guided aspirate of peri-graft
fluid
• Blood culture(s) positive and
no apparent source except
AGI
• Abnormally elevated
inflammatory markers with
AGI as most likely cause e.g.
ESR, CRP, white cell count
Prevention
Current recommendations for prevention include intravenous antibiotics 30–60min prior to incision to address both
gram-positive and gram-negative bacteria. For patients with
known MRSA colonization, vancomycin should be administered 60–120min prior to incision (due to its slower distribution) with an additional antibiotic for gram-negative
organisms. Antibiotics should be continued for 24 h.
Preprocedure, patients should have careful inspection of the
groins even if groin incisions are not planned. Incisions
through areas where excoriation or rash are present should
not be done for elective procedures. Hair on the abdomen
and in the groins should be clipped and not shaved due to the
increased risk of skin trauma with razor use. Preprocedure
shower with antimicrobial soap is recommended for both
hospitalized and same-day admission patients. Antimicrobial
incisional drapes are routinely recommended. Dressings
should remain intact for the rst 24–48h unless signicant
drainage is present [94]. Any signs of supercial wound
infection or breakdown should be aggressively treated.
Management ofAortic Graft Infections
The management of graft infections is similar to the management of primary aortic infections, and is based upon the principles of source control of the infection and restoration of
perfusion to critical organs. Initial drainage procedures
should be considered if the patient is hemodynamically stable and without anastomotic disruption. Antibiotics should
be initially broad spectrum and narrowed based on culture
results. The surgical options for reconstruction are the same
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as for primary aortic infections although there appears to be
an increasing trend toward in situ reconstructions with
homograft due to the emergent nature of many of these infections with either anastomotic disruption or aortoenteric stula [87, 99]. Elimination of the dead space and coverage of
all new graft material and stump closures should be a planned
part of the procedure. Others have also emphasized the difference between the Samson classications of aortic graft
infections and tailored treatment accordingly. This strategy
led to excision of only 10/34 infected grafts in the original
series published by Samson with only 11 graft infections
ultimately requiring total removal, 2 deaths (6% mortality),
and limb loss in 8 patients (24%) [114]. Some have advocated treatment algorithms based on blood culture results
with in situ reconstruction being recommended only for
patients with negative cultures [108]. The additional benet
of in situ reconstruction is in cases where there is the late
development of pseudoaneurysm, calcication, or aneurysmal dilation, and endovascular options for subsequent repair
exist and may be far less morbid (see Case #1– Fig.17.1).
For cases of extra- anatomic reconstruction with aortic stump
closure, the risk of aortic stump blowout remains high at
30% and reinfection occurs in 5–15% [87, 115, 116].
Aortic graft infections remain a lethal condition with
series reporting mortality ranging from 8% to over 50% with
morbidity rates of 60% and higher [46, 117]. Some have
noted that this wide range is more consistent with the patient’s
concomitant illnesses rather than the type of surgical procedure with increasing mortality observed in patients with coronary disease, chronic obstructive pulmonary disease, and
diabetes [99]. One series identied those patients greater than
70 years of age, CRP >5.0 mg/dl, and serum creatinine
>1.2mg/dl as having a mortality of greater than 90% for in
situ reconstruction with allograft [99]. Consequently, it is
appealing to attempt to restrict the surgical approach to something more limited in patients with increased risk of mortality.
Conservative management with intravenous antibiotics and
drainage has been done with generally poor patient outcomes.
The exception to this appears to be in cases of isolated graft
infection in the groin (for those patients treated with aortobifemoral grafts) where there is a growing trend toward preservation of the graft with long-term antibiotics and sartorius
muscle ap coverage with adjunctive negative pressure
wound therapy with good patency and long-term survival
[118, 119]. Conservative management in cases where the aor-
tic portion of the graft is involved is not routinely recommended for patients since mortality frequently occurs within
2 years [120–122]. Rare survivors have been reported with
this strategy [40, 107, 109]. Consequently, to be considered
for this option, a patient should have prohibitive comorbidities, infection limited to the body of the graft (without extensive surrounding tissue infection), and a culture of an indolent
gram-positive organism. Other options for conservative therapy include intravenous antibiotics with percutaneous drain-
age [123], irrigation and perigraft debridement [78, 124], and
muscle and/or omental aps [118, 125]. Some have advocated a combined approach with suppressive antibiotic therapy and drainage for high-risk patients as long as cultures do
not show invasive gram-negative infections such as
Pseudomonas or Salmonella. Drainage of the perigraft space
can be done percutaneously or with laparotomy with the goal
of continual irrigation of the space until the cultures are negative. Long- term survivors have also been reported with this
management [122]. There is a growing experience in using
endovascular techniques to temporize and stabilize the critically ill patients with graft infections, particularly those who
present with aortoenteric [126] or aortobronchial stulae
[127]. The obvious concern in these patients is that the
remaining hole in the airway or viscera is untreated and
remains a continual source of bacterial contamination. This
has led to the recognition that this treatment is a bridge to
denitive therapy and not as adequate treatment [27].
Case report
A 65-year-old patient with a history of an aortic tube graft has
recurrent GI bleeding. CT imaging and radionucleotide imaging failed to identify infection (Case #2 – Fig. 17.6).
Endovascular therapy with aortic cuff placed at the proximal
anastomosis was performed. Six months later, CT reveals air
around the stent graft (Fig.17.6a). At the time of exploration,
periaortic phlegmon was encountered (Fig.17.6b) and aortic
reconstruction was performed with cryopreserved graft and
omental wrap. The graft was intact at explantation (Fig.17.6c).
Surgical options previously described for the treatment of
primary aortic infections remain the gold standard for treatment of aortic graft or endograft infections. Suprarenal xation with some aortic endografts can make excision of these
graft materials even more challenging than simple excision of
an infrarenal graft, but the reconstructive options remain the
same. Given the complexity of these patients, advocating for a
specic treatment algorithm for each type of procedure is difcult. Some observations can be made, however, based on the
existing literature [107]. In situ reconstructions can be performed with rifampin-impregnated Dacron [45] or homograft
[128] for patients with indolent infections. Risk factors for
mortality have been identied in previous studies and include
age >70, creatinine >1.2 mg/dl and C-reactive protein >5.0.
Patients with only one risk factor have been documented to
have an in-hospital mortality rate of 7.7% and mortality >90%
when two or more are present. There has been no statistically
signicant difference found with the duration of aortic clamping, transfusion requirements, or use of vasopressors between
survivors and nonsurvivors [99]. The strategy of excision and
in situ reconstruction does not appear to be as durable for
patients with aggressive gram-negative infections, extensive
surrounding necrosis or contamination, or those with fungal
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a
b
c
Fig. 17.6 Case #2. (a) CT scan showing air around existing graft. (b)
Intraoperative appearance of retroperitoneum. Iliac arteries at top of
image. (c) Aortic tube graft and endovascular extension cuff after
infections with subsequent infectious complications occurring
5 times more frequently in these patients [45]. For wellselected patients, in situ reconstruction with allograft affords a
durable repair with survival of 82% at 2years [129]. Longterm degeneration of the graft remains a concern, but accumulated data has shown an extremely low incidence [130]. Staged
procedures with extra-anatomic reconstruction being performed through clean elds with subsequent aortic graft excision at a later surgery appear to afford the surgeon an easier
operation with improved patient survival (13%) when compared to a single-stage procedure (26%) [54, 55, 129]. The
long-term patency of these constructs is not as robust with
3-year primary patency rates reported as low as 43% and
amputation rates ranging from 6% to 25% with most authors
reporting a 10% rate of limb loss at 5 years [26, 55, 131].
These patients also have the risk of rupture of the aortic stump
closure [84, 87]. The NAIS procedure appears to be a durable
reconstruction that is resistant to subsequent infection but
explantation. Note minimal tissue incorporation around graft. (Images
courtesy of Raghu Motaganahalli, MD)
remains as a long, technically demanding procedure [56, 132].
In a meta-analysis comparing the different surgical options of
extra-anatomic bypass, rifampin-bonded synthetic grafts,
cryopreserved allografts, and autogenous venous grafts, statistically signicant differences were observed. Extra-anatomic
bypass procedures had higher mortality and amputation rates
than reconstruction with rifampin-bonded grafts, higher rates
of thrombosis compared to cryopreserved grafts, and higher
infection rates than autogenous vein grafts. Overall, the complication rates, reinfection rates, and mortality were higher
than with another other reconstructive procedures [87].
Caution is urged when interpreting such data, however, as the
data may be seriously impacted by the inclusion criterion,
higher number of patients with Samson class V infections, and
referral bias from individual studies [80].
Patients who present with aortoenteric stula require a
clear understanding of the management strategy for both
control of hemorrhage and infection. Most present with
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271
symptoms of an upper gastrointestinal bleed. If hemodynamically stable, CT scanning can alert the clinician to the
proximity of the bowel to the graft. While endoscopy is useful to demonstrate the area of erosion, this should only be
attempted in a surgical environment where large bore intravenous access has been established and there is an immediate ability to proceed with emergent laparotomy to control
hemorrhage. Temporary supra celiac control may be achieved
with an endovascular balloon or by direct surgical exposure.
Control of the iliac arteries should proceed expeditiously.
Aggressive efforts should be made to dissect the bowel free
and enable an infrarenal clamp to be placed whenever possible. In some patients, there may not be enough aortic neck
to allow this and the next critical step in management is over
sewing of the aortic stump as previously discussed. Once
control of hemorrhage is obtained, denitive excision should
be performed and reconstructive options may be considered.
Previously, the “gold standard” was extra-anatomic reconstruction with high rates of complications and mortality [26,
54, 85, 133–139]. For patients with less aggressive infec-
tions, in situ reconstruction with allograft or native vein is a
durable option associated with less morbidity and mortality
[50, 87, 129, 140–143]. Unfortunately, for the majority of
these patients, the type of infection is not known at time of
emergent operation and the decision as to which procedure is
best is left to the discretion of the surgeon. Postoperatively,
parenteral antibiotics for 6 weeks is recommended (AHA)
with most recommending 3–6months of oral antibiotic therapy and a consideration for lifelong oral antibiotic suppression for patients with extensive or aggressive infections [80].
Current Recommendations forTreatment
The AHA has published guidelines to aid the clinician when
confronted with these challenging patients. For patients with
Samson class I or II infections, surgical debridement and
2–4weeks of antibiotic therapy is an appropriate choice. For
Samson class III or IV patients, initial therapy of 4–6weeks
may be extended up to 6months. For those patients presenting as class V, 4–6weeks of parenteral antibiotic therapy is
recommended with an additional 6 months of suppressive
antibiotic therapy. These current recommendations also
emphasize the difference in treatment for aggressive pathogens with MRSA, pseudomonas, multidrug-resistant organisms, and fungal infections with a recommendation for
long-term suppressive therapy. Patient factors such as multiple prior procedures, in situ reconstructions, or those who are
poor candidates for surgical procedures may also be considered for long-term antibiotic therapy [80].
When considering surgical options for these patients, the
AHA has also offered some recommendations. For early
(<2months) Samson class III infections, graft preservation
can be considered with appropriate antibiotic therapy and
follow-up. Late (>2 months) Samson class III infections
should be considered for graft excision and reconstruction
instead of preservation. For class III or IV infections with
aggressive infections as previously discussed, extra- anatomic
reconstruction with graft excision is the treatment of choice.
Class V patients should be treated with prompt extraanatomic revascularization followed by graft excision. The
guidelines also emphasize ultrasound imaging as a routine
part of follow-up every 3 months for the rst 2years followed by ultrasound examination every 6–12months thereafter. What makes these guidelines difcult to apply globally
is that there is no standard surgical option and no specic
recommended operation for each type of infection as individual patient factors, surgeon experience and available
resources will impact management.
Conclusion
Evaluating the literature for primary aortic infections, infectious aneurysms, aortic graft infections, and endovascular
graft infections is difcult. Most publications include case
reports or small numbers of patients and are retrospective
analyses of operations performed at the discretion of the surgeon caring for the patient. Often, “aortic infections” are
grouped in these studies to include both primary infections
and graft infections and complications, and mortality rates
are reported as a composite endpoint for the total group.
Long-term follow-up is frequently limited. In addition, the
bacteriologic prole of aortic infections has changed in
recent years as well as the baseline characteristics of patients
with a signicantly higher proportion of patients having
extensive cardiac and pulmonary disease [144]. The comparison of newer types of reconstruction to older procedures
in historical series may be inherently biased by modern anesthesia and postoperative critical care which may affect both
morbidity and patient survival. Despite these issues, the principle of treating aortic infections remains consistent.
Management of these patients involves a multidisciplinary
team composed of experts in infectious disease, cardiology,
radiology, and surgery. Intravenous broad-spectrum antibiotics should be administered when infection is suspected and,
as a general rule, all infected material should be removed and
perfusion restored to critical organs and the extremities.
4–6 weeks of parenteral antibiotics are recommended as a
minimum with consideration for 6months, or lifelong suppression should be considered in cases of extensive infection
or infections with aggressive organisms. Signicant postoperative complications depend on the type of reconstruction
with increased risk of graft thrombosis and amputation
occurring in extra-anatomic grafts, increased risks of infection with synthetic grafts, and increasing durability with
272
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C. M. Wittgen et al.
native vein constructs and allografts. Sound knowledge of
the types of reconstruction can help the vascular surgeon
decide the appropriate treatment for these patients with this
highly lethal disease.
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