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5.4 Perioperative Management
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Studies
A Cochrane review [75] on abdominal aortic graft infections states:
• Abdominal aortic graft infections can be treated surgically or conservatively
using medical management. The two most common surgical techniques are in
situ replacement of the graft and extra-anatomical bypass. Medical management
most commonly consists of a course of long-term antibiotics. There is currently
no consensus on which intervention is the most effective in managing abdominal
aortic graft infections. Whilst in emergency or complex situations such as graft
rupture surgical management is the only option, in non-emergency situations it is
often personal preference that inuences the clinician’s decision-making. There
is currently insufcient evidence to draw conclusions to support any treatment
over the other. Multicentre clinical trials are required to compare different treat-
ments for the condition.
A systematic review on the management of open abdominal aortic graft infections
was performed by Post and Vos [76]. They included 32 publications with a total of
1316 patients. The meta-analysis showed that overall 30day mortality and 1year
survival for treatment of aortic graft infection is 13.5% and 73.6%, respectively.
Extraanatomic repair, once the gold standard, had the highest 30-day mortality
(26.7%) and lowest 1year survival (54.3%) rates. Limb salvage rates were high
(95%) for all subgroups and recurrent infection rates were low (approximately 5%)
except for those studies in which partial graft removal was performed (39.3%).
Subgroup analyses of graft material used for in situ replacement demonstrated better survival and mortality rates for prosthetic grafts, although these grafts performed
worse compared with supercial femoral veins and arterial allografts in terms of
limb salvage and infection recurrence rates. Patency at 1 year was comparable
between all subgroups studied.
The rst systematic review with meta-analysis of all data (31 studies, 1377
patients) available on in situ reconstruction with cryopreserved allografts for arterial
reconstruction after aortoiliac infection was performed by Antonopoulos etal. [77].
30-day mortality was 14.9%. Peri-anastomotic rupture/allograft disruption rate was
5.9%, while pooled aneurysmal degeneration/allograft dilatation was 4.99%. A
pooled rate of 3.11% was estimated for pseudoaneurysm formation after the use of
cryopreserved arterial allografts, while the allograft thrombotic/stenotic complication rate and perianastomotic infection were 12.19%, respectively. Mortality during
follow up was 19.24%, while allograft related mortality during follow up was
3.58%. A pooled allograft related re-operation rate was estimated at 24.87%. The
authors considered in situ reconstruction with the use of cryopreserved allografts as
a safe and durable option with acceptable outcomes for treatment of aorto-iliac
infection
Alonso etal. [78] reported the surgical strategy and early outcomes of abdominal
aortic reconstruction in both native and graft-related aortic infection with in situ
xenopericardial grafts. In situ xenopericardial aortic reconstruction in 21 patients
resulted in 4.7% 30-day mortality, 19% overall mortality, and 95% primary patency
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with a median follow up of 14months. Combined with debridement and an appropriately long course of antibiotics, in situ xenopericardial aortic reconstruction was
a safe and effective management strategy for both native and graft-related abdominal aortic infection with good short-term results.
Bovine pericardium was also used by Almási-Sperling et al. [79] for in situ
reconstruction of infected grafts. Graft reconstructions were related to the descending aorta (n=1), abdominal aorta (n=5), iliac arteries (n=4) and femoral arteries
(n=9). Ten patients (53%) had a complication perioperatively and postoperatively.
The 30-day mortality was 10.5%; the total mortality rate after 1year was 32%.
There was no reinfection after bovine reconstruction observed. Graft occlusions
were detected in two cases during follow-up (median, 6months; range, 1–47months).
A third retrospective analysis of patients in whom bovine pericardial grafts
(BPGs) had been used for the management of aortic graft infection or aortic reconstructive surgery in the presence of systemic infection was presented by Burghuber
etal. [80]. Twenty-one patients had received BPGs. The 30-day mortality was 9.5%
and the 2-year survival rate was 75%, with a primary assisted patency rate of 94%
and freedom from reinfection of 89%. Considering that antibiotic-impregnated/
silver- coated polyester grafts are reported to have a higher reinfection rate than
biological materials, the authors considered bovine pericardial prostheses to be a
good alternative. However, case series without a control group do not allow a nal
conclusion.
5 Abdominal Aortic Aneurysm (AAA)
5.4.5 Endovascular Repair ofNonruptured AAA
5.4.5.1 Anaesthesia
Studies
A systematic review is available for the effect of mode of anesthesia on outcome
from EVAR [81]. 16 studies in 23,202 patients compared local anaesthesia (LA) to
general anaesthesia (GA) and reported in-hospital mortality/30-day mortality. The
unadjusted risk of death after emergency EVAR with LA was lower than with
GA.Trends in elective surgery were less clear. Randomised trials were lacking.
The aim of a systematic review and meta-analysis performed by Harky etal. [82]
was to compare the clinical outcomes of using local/regional anesthesia (LA/RA)
versus GA in nonemergency EVAR.A total of 12,024 patients (n=1664 LA/RA,
n=10,360 GA) were analyzed from 12 observational studies included in this analysis. Shorter total surgical time in LA/RA patients was reported (135±40 min v
164±43min; p<0.00001). Shorter hospital stay was observed in LA/RA patients
(3.6±3.3 d v 4.6±5 d; p=0.002). No difference in cardiac or renal complications
was noted between the LA/RA and GA groups postoperatively. Similarly, no difference in vascular complications was noted in LA/RA versus GA patients. Thirty-day
morality was not different between the two cohorts. Use of LA/RA in selective
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endovascular abdominal aortic aneurysm repair procedures provides satisfactory
and comparable perioperative outcomes with those of GA, with the advantage of a
shorter hospital stay. A large randomized controlled trial or multicenter study is
required to conrm these ndings.
Van Orden et al. [83] identied 8141 percutaneous EVARs in the Vascular
Quality Initiative (VQI) database. GA was used in 7387 (90.7%) cases, whereas LA
was used for 754 (9.3%) of cases. Multivariable analysis showed that GA compared
with LA was associated with more pulmonary complications (odds ratio, 2.8; 95%
condence interval, 1.49–5.43; P = .002) and prolonged operative time (means
ratio, 1.11; 95% condence interval, 1.08–1.52; P<.001). There was no independent effect on overall complications, cardiac complications, or mortality. Surgeons
should consider expanding the use of LA for percutaneous EVAR when feasible.
Data from the UK’s National Vascular Registry were analysed by Dovell etal.
[84]. A total of 9783 patients received an elective, standard infrarenal EVAR (GA,
n=7069; RA, n=2347; and LA, n=367) across 89 hospitals. Thirty-day mortality
was signicantly lower in the RA group compared with the GA group, but mode of
anaesthesia was not associated with increased complications for patients undergoing elective standard infrarenal EVAR.The previously observed reduction in pulmonary complications associated with LA in elective EVAR was not reproduced in
this cohort. This retrospective analysis of a contemporary national database contributes to the evolving evidence base and clinical equipoise surrounding the choice of
anaesthetic technique for EVAR.
5.4.5.2 Percutaneous Access
The ESVS guidelines [1] recommend:
• Recommendation 55: An ultrasound guided percutaneous approach should be
considered in endovascular aortic aneurysm repair. (Class IIa; Level B)
Studies
In the so-called PiERO study [85], patients with an abdominal aortic aneurysm suitable for EVAR were randomized to open or percutaneous access of the main device
(MD) through the common femoral artery (CFA). Both groups contained 137
groins. A major strength of the PiERO trial was the comparison of two techniques
in one patient. No difference in surgical site infections or wound complications was
found, but a reduction of pain and wound inammation was observed in the percutaneous access group. The patient’s comfort did improve.
Perioperative outcomes of percutaneous EVAR were analysed by Siracuse etal.
[86] using the Vascular Quality Initiative (VQI) database. In 8340 patients (64%),
endovascular aneurysm repair through a percutaneous approach resulted in reductions in operative time, blood loss, and length of stay compared with results in 4747
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5 Abdominal Aortic Aneurysm (AAA)
patients who underwent abdominal aortic aneurysm repair by open surgical access.
The percutaneous approach failed in 4%, most frequently with previous bypass procedures, ruptured aneurysms, general anesthesia, female sex, obesity, coronary disease, and preoperative aspirin use. Early results of this study suggest that a
percutaneous approach should be used for endovascular aortic aneurysm repair.
A meta-analysis comparing open vs. percutaneous access in EVAR is now available [87]. Four RCTs were identied, reporting a total of 368 patients and 530
access sites. Meta-analysis showed no difference in access site complications or
infection, post-operative bleeding/haematoma, access related arterial injury, femoral artery occlusion, pseudo-aneurysm, or peri-operative mortality between percutaneous and cutdown EVAR.Seroma/lymphorrhoea was signicantly less frequent
after percutaneous EVAR compared with cutdown EVAR and the procedure time
was signicantly shorter, but hospital length of stay was not different between treatments. The evidence is very uncertain about the effect of percutaneous EVAR on
clinically important outcomes.
5.4.5.3 EVAR Outside theInstructions forUse
Studies
In a systematic review, Antoniou etal. [88] investigated whether patients undergoing standard endovascular aneurysm repair outside the instructions for use (IFU)
have worse outcomes than patients treated within IFU. 17 observational cohort studies published between 2011 and 2017, reporting a total of 4498 patients were identied. The pooled prevalence of EVAR performed outside the IFU was 40%.
Nonadherence to IFU was not associated with increased risk of perioperative mortality, aneurysm rupture, aneurysm-related mortality, technical failure, requirement
for adjunctive procedures, type I endoleak, aneurysm sac expansion, or aneurysmrelated reintervention. The overall mortality was signicantly higher in patients
treated outside the IFU.Meta-regression showed that the prevalence of EVAR performed outside the IFU has increased over time (P=.019). Standard EVAR outside
the IFU could be considered in selected patients who are deemed high risk for complex open or endovascular surgery.
The long-term results of outside IFU EVAR were examined by Oliveira-Pinto
etal. [89]. 13 studies were included in this review. Although overall mortality and
aneurysm-related mortality did not seem to differ signicantly at long-term, higher
rates of type I endoleaks may be expected, mainly in short necks. However, for
patients with severe angulation or high thrombus load in the proximal neck, results
of outside IFU EVAR seem to match the results of EVAR within IFU.
5.4.5.4 Prevention ofContrast-Induced Nephropathy (CIN) withEVAR
The ESVS guidelines [1] recommend:
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• Recommendation 38: Patients with renal impairment should be adequately
hydrated before elective abdominal aortic aneurysm repair, and estimated glo-
merular ltration rate, uid input, and urine output should be monitored after
abdominal aortic aneurysm repair to recognise and manage reduced kidney func-
tion. (Class I; Level C)
The guideline of the European Society of Cardiology (ESC) and European
Association for Cardio-Thoracic Surgery (EACTS) [90] recommends:
• Especially if glomerular ltration rate (GFR) is <40mL/min/1.73m2, all patients
with chronic kidney disease who undergo diagnostic catheterization should
receive preventive hydration with isotonic saline, to be started approximately
12h before angiography and continued for at least 24h afterwards to reduce the
risk of contrast-induced nephropathy (CIN). The implementation of high-dose
statin before diagnostic catheterization has been shown to reduce the incidence
of CIN and should be considered as an additional preventive measure in patients
without contraindications.
Studies
Ma etal. [91] conducted a network meta-analysis to evaluate the relative efcacy of
pharmacological interventions for the prevention of CIN.They found 107 trials
comprising 21,450 participants and 11 pharmacological interventions. Compared
with intravenous saline, intravenous saline + statin + N-acetylcysteine (NAC)
seemed to be the most effective treatment for the prevention of CIN in patients after
coronary angiography. NAC+intravenous saline may have a protective role against
short-term all-cause mortality. However, none of these drugs has effectively
decreased the requirement for dialysis and the rate of major cardiac and cerebrovascular adverse events.
A second meta-analysis compared the preventive effect of strategies to reduce
CIN, including subgroup analyses based on route of administration of contrast
media and the type of contrast media used [92]. In this study, evidence for a clinically important and statistically signicant benet regarding CIN prevention was
found for three strategies:
• Low-dose NAC+intravenous saline compared with intravenous saline alone.
• NAC+i.v. saline vs. i.v. saline in patients receiving low-osmolar contrast media.
• Statins+NAC+i.v. saline vs. NAC+i.v. saline.
A clinically important difference that was not statistically signicant was seen for:
• Sodium bicarbonate vs. i.v. saline in patients receiving low osmolar con-
trast media.
• Statins + i.v. saline vs. i.v. saline alone.
• Ascorbic acid + i.v. saline vs. i.v. saline alone.
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Strength of evidence was generally insufcient for comparisons of the need for
renal replacement, cardiac events, and mortality. The greatest reduction in CIN was
seen with N-acetylcysteine plus i.v. saline in patients receiving low osmolar contrast
media and with statins plus N-acetylcysteine plus i.v. saline.
5.4.5.5 Preservation ofFlow totheInternal Iliac Artery
The Society for Vascular Surgery practice guidelines [2] recommend:
• We recommend preservation of ow to at least one internal iliac artery. Level of
recommendation 1 (Strong). Quality of evidence A (High)
• We recommend using FDA-approved branch endograft devices in anatomically
suitable patients to maintain perfusion to at least one internal iliac artery. Level
of recommendation 1 (Strong). Quality of evidence A (High)
• We recommend staging bilateral internal iliac artery occlusion by at least
1–2weeks if required for EVAR.Level of recommendation 1 (Strong). Quality
of evidence A (High)
Studies
A signicant proportion (up to 40%) of patients with AAA have an ectatic or aneurysmal common iliac artery (CIA). In the absence of an adequate iliac artery landing
zone, EVAR requires exclusion of one or both internal iliac arteries (IIAs) and
extension of the stent graft to the external iliac artery. In most of these patients,
embolization of one or both IIAs is required to prevent backbleeding from the
IIA.The aim of a study presented by Kouvelos etal. [93] was to review all studies
on IIA sacrice during EVAR and analyze the clinical effect of IIA interruption.
Furthermore, all reported cases that involved preservation of IIA were reviewed to
investigate technical and clinical outcome. In this systematic review the pooled
30-day buttock claudication rate was 29.2%. Patients undergoing bilateral IIA interruption had a higher incidence of buttock claudication than patients with unilateral
IIA interruption (36.5% vs. 27.2%; p = .01). During a median follow up of
17months, the pooled rate of persistent buttock claudication was 20.5%. In patients
with an iliac branched device, technical success was 96.2%. Within 30 days of
EVAR, 4.3% of internal iliac branches occluded. The pooled buttock claudication
rate on the side of the IIA revascularization during follow up was 4.1%. IIA preservation techniques represent a signicant improvement in the treatment of aorto-iliac
aneurysms and have been associated with high technical success and low morbidity.
According to a systematic review by Bosanquet et al. [94], 15% of EVARs
require internal iliac artery (IIA) sacrice. Buttock claudication occurred in 27.9%
of patients, although 48% resolved after a mean of 21.8months. Erectile dysfunction was reported in 10.2% of males, with higher rates after coiling. Buttock claudication rates were 32.6% with coils, 23.8% with plugs, and 12.9% with coverage
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alone, and less with unilateral (vs. bilateral) IIA treatment. More proximal coil
placement resulted in lower rates of buttock claudication. Type II endoleaks were
more frequent after covering alone; however, re-interventions were rare. Signicant
ischaemic events (bowel/gluteal/spinal ischaemia) were very rare. Plugs were
quicker to place and required less radiation (p<.001) than coils. Where both options
are technically possible, plugs could be considered preferential to coils, and placed
as proximally in the IIA as possible.
Medium-term results are available for two techniques to maintain blood ow in
the IIA, the use of iliac-branched prostheses and the so-called parallel graft techniques (sandwich graft, chimney). The most used technique here is the internasnorkel technique, in which a covered stent is inserted into the IIA parallel to the
main graft, allowing retrograde perfusion of the IIA [95]. In a review, Oliveira-Pinto
etal. [96] found similar short-term outcomes for the iliac branch extension device
(IBED) and the parallel graft—“sandwich” technique (PG-ST). Both IBED and
PG-ST have proven to be safe and valid approaches. However, while IBED has
established as a durable procedure, mid-term data lacks on PGs performance and
further studies are required to attest durability of the latter procedure.
5.4.5.6 Stent Graft Migration
Studies
Device migration is a common complication that requires secondary intervention
following EVAR. It is dened as displacement of the endograft by more than
5–10mm from its original position. It is often due to progressive dilatation of the
aneurysm neck but can also be related to aortic tortuosity, aortic wall degeneration
after endograft placement or may be secondary to graft over- or undersizing. Device
migration is associated with endoleaks, aneurysm sac expansion and possible rupture. Device migration has been reported to occur following 1.0–2.8% of TEVAR
procedures and 1–10% of endovascular repair of the abdominal aorta at 1year postintervention. In cases of aortic endograft migration, treatment is very similar to
management of a type I endoleak. Endovascular treatment options include the use
of aortic extension cuffs or placement of large balloon-expandable stents to augment the xation of the endograft to the native aortic wall and thus extend the xation zone. Another option is that of using endostaples to secure the graft to the aortic
wall [97].
Muhs etal. [98] examined whether prophylactic use of EndoAnchors contributes
to improved outcomes after endovascular aneurysm repair (EVAR) of abdominal
aortic aneurysms. In propensity-matched cohorts (99 pairs matched), most with
hostile neck, prophylactic use of EndoAnchors during elective endovascular aortic
aneurysm repair resulted in similar rates of freedom from type I endoleak, neck
dilation, or sac enlargement but a signicantly higher rate of sac regression during
a 2-year follow-up.
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A retrospective review of a prospective database of 42 patients with hyperangulated necks (>60°) who underwent EVAR with supplementary endostapling was
undertaken by Chaudhuri etal. [99]. The study specically examined hostile neck
anatomy in the context of hyperangulated necks, and whether using targeted adjunct
xation with the Heli-FX EndoAnchor (EA) system can achieve acceptable sealing
augmentation and prevent complications such as type Ia endoleaks and migration.
Mean follow-up time was 18.5months. One patient had persistent type Ia endoleak,
successfully banded. There was 6.8±10.2mm sac size reduction (p<.001). There
were no other neck-related reinterventions, despite continued neck dilatation
(3.2±3.7mm, p<.001). The study suggested successful EVAR with adjunct endostapling for AAA with hyperangulated necks, with signicant sac shrinkage and low
rates of endoleaks, migration and reinterventions.
5.4.5.7 Endoleak
The ESVS guidelines [1] recommend:
• Recommendation 86: In patients with Type I endoleak after endovascular
abdominal aortic aneurysm repair, re-intervention to achieve a seal, primarily by
endovascular means, is recommended. (Class I; Level B)
• Recommendation 87: Expansion of sac diameter≥1cm detected during follow
up after endovascular abdominal aortic aneurysm repair using the same imaging
modality and measurement method may be considered as a reasonable threshold
for signicant growth. (Class IIb; Level C)
• Recommendation 88: Re-intervention for Type II endoleak after endovascular
abdominal aortic aneurysm repair should be considered in the presence of sig-
nicant aneurysm growth (see Recommendation 87), primarily by endovascular
means. (Class IIa; Level C)
• Recommendation 89: In patients with Type III endoleak after endovascular
abdominal aortic aneurysm repair, re-intervention is recommended, primarily by
endovascular means. (Class I; Level C)
• Recommendation 90: Signicant aneurysm sac growth after endovascular
abdominal aortic aneurysm repair, without visible endoleak on standard imag-
ing, should be considered for further diagnostic evaluation with alternative imag-
ing modalities to exclude the presence of an unidentied endoleak, and should be
considered for treatment. (Class IIa; Level C)
Studies
Cannavale etal. [100] outlined the most recent concepts on imaging follow-up,
pathophysiology/risk factors, and management of endoleaks. The results of this
review are shown in Table5.4. Prevention and treatment of endoleaks have reached
high success rates, with low complication and endoleak recurrence rates. Type 2
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Table 5.4 Treatment modalities in type I and II endoleaks (according to [100])
Treatment modality
Endoleak type Ia
• Aortic balloon angioplasty+cuff/
stent-extension-reinforcement
• Embolisation (coils and glue)
• Endo-Anchors
• Parallel stent grafts
• Surgical conversion
Endoleak type Ib
– Limb extension
– Embolisation internal iliac artery
– Surgical/hybrid access
Endoleak type II
– Transarterial embolisation
– Translumbar direct sac puncture
– Transcaval embolisation
– Surgical laparoscopic/open
Technical
success
100%
90–100%
90–100%
90–94.4%
>90%
100%
100%
>90%
62.5–84%
81–98.7%
93.7%
90%
Freedom from recurrent
endoleak
87%
80%
95–97%
90–100%
Not reported
94% without embolisation
75%
Not reported
64.2%
81%
Not reported
100%
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endoleaks (T2EL), caused by backow of collateral arteries into the aneurysm sac,
are the most frequently encountered and may account for the need for secondary
interventions after EVAR in up to 40% of the cases. Support for conservative management of T2EL derives from the relatively high percentage of T2EL that will
resolve spontaneously over a variable period (more than 30%) and the estimated
low risk of post-EVAR rupture secondary to isolated T2EL (less than 1%) [101].
Dijkstra etal. [102] reported the incidence, natural history, and outcome of type
II endoleaks in the largest prospective real-world cohort to date. The ENGAGE
registry included 1263 patients. Through 5years of follow-up, a total of 197 (15.6%)
patients with isolated type II endoleaks were identied. Most were detected within
the rst 30days (37.1%) and through the rst year (37.1%), with the remainder
being detected after 1year of follow-up (25.8%). Patients with a type II endoleak
had a higher incidence of aneurysm growth and more secondary endovascular procedures (15.4% vs 7.5% at 5years; P<.001). Overall survival was higher in the
isolated type II endoleak group compared with patients with no endoleak (77.2% vs
67.0% at 5years; P = .010). Twenty-two patients (10%) with a type II endoleak
were diagnosed with a late type I endoleak (type IA, n=10; type IB, n=12), with
a secondary intervention rate of 67.5% through 5years. Most of the type II endoleaks do not require secondary intervention. However, a small group of patients with
a type II endoleak will present with a type I endoleak, resulting in a high secondary
intervention rate and signicant risk of aneurysm-related complications.
A systematic review and meta-analysis on pre-emptive aortic sidebranch embolization to prevent T2EL after EVAR was performed by Yu etal. [103]. Together
with 13 studies from a previous search, a total of 17 studies were included in this
updated analysis. Pre-emptive embolization was performed 1–28days before the
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5 Abdominal Aortic Aneurysm (AAA)
EVAR procedure in six studies. In seven studies, embolization of aortic side
branch(es) was performed simultaneously with the EVAR procedure. Four studies
did not specify the timing of pre-emptive embolization in relation to the EVAR
procedure. Based on 16 studies, the incidence of T2EL was 19.7% (145/735) in the
embolization group vs 37.4% (456/1220) in the control group (OR, 0.38), after a
median follow-up of 21.3months. Based on 12 studies, the incidence of reintervention for T2EL was 1.2% (7/570) in the embolization group vs 11.2% (84/753) in the
control group (OR, 0.12) after a median follow-up of 24.1months. With a lower
incidence of T2EL, aneurysm sac growth, and reintervention rate, pre-emptive
embolization can potentially reduce the frequency of surveillance and improve the
long-term durability of EVAR.However, a higher level of evidence is still required
to support a broad change of practice, including data on cost-effectiveness and on
the potential effect on rupture.
5.4.5.8 Stent Graft Infection
Studies
A meta-analysis based on 12 studies reporting on 362 patients is available on the
outcome of endograft infection after EVAR [104]. The incidence of graft infection
was 0.6%. Surgical treatment was performed in the majority of patients (n=293,
81%; 233 [64%] in situ reconstructions, 58 [16%] extra-anatomical bypasses, 2
endovascular interventions). Aortic replacement with a prosthetic graft was performed in 58%, whereas cryopreserved allografts and autologous grafts were used
in 31% and 11%, respectively. The pooled estimate of 30-day/in-hospital mortality
was 26.6%. The pooled 30-day/in-hospital mortality for nine patients treated conservatively was 63.3%. The pooled overall follow-up mortality was 45.7% vs 58.6%
for the nine patients receiving conservative treatment. Surgical treatment with complete explantation of the infected endograft seems to be the optimal management in
selected patients.
Another meta-analysis is based on 11 studies with 402 patients [105]. Most of
the endografts were implanted for EVAR (351/402, 87%), while the other 51 (13%)
endografts were infected following TEVAR.Among the 402 patients, 39 (9.7%)
patients presented with aortic rupture. Ninety-two of 380 (24.2%) patients with
available data had aortoenteric stula (AEF). 69 patients (17%) died in hospital or
within 30days after operation. 114 patients (28%) died during follow-up. 42 patients
(10%) received conservative treatment, whereas 359 (90%) patients underwent surgical treatment, including stent graft removal with in situ reconstruction or extraanatomical bypass, and secondary endovascular procedure. Patients in the surgical
group had a higher survival rate compared with conservative group (58% vs. 33%,
P=0.002). This analysis suggests that surgical treatment is a better option compared with conservative management in selected patients with aortic endograft
infection.
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