How To Diagnose and Manage Infected Endografts after Endovascular Aneurysm Repair

Abstract

The prevalence of endograft infections (EI) after endovascular abdominal aortic aneurysm repair is below 1%. With the growing number of patients with aortic endografts and the aging population, the number of patients with EI might also increase. The diagnosis is based on an association of clinical symptoms, imaging, and microbial cultures. Angio-computed tomography is currently the gold-standard technique for diagnosis. Low-grade infection sometimes requires nuclear medicine imaging to make a correct diagnosis. There is no good evidence to guide management so far. In the case of active gastrointestinal bleeding, pseudoaneurysm, or extensive perigraft purulence involving adjacent organs, an invasive treatment should always be attempted. In the other cases (the majority), when there is not an immediate danger to the patient's life, a conservative management is started with a proper antimicrobial therapy. Any infectious cavity can be percutaneously drained. Management depends on the patient's condition and a tailored approach should always be offered. In the case of a patient who is young, has a good life expectancy, or in whom there is absence of significant comorbidities, a surgical attempt can be proposed. Surgical techniques favor, in terms of mortality, patency, and reinfection rate, the in situ reconstruction. Choice of technique relies on the center and the operator's experience. Long-term antibiotic therapy is always required in all cases, with close monitoring of the C-reactive protein.

Pyrexia in an older man, months after emergency

“…Endovascular abdominal graft infection is rare, with an incidence of around 1% 1. The incidence is increasing, driven by the growing number of procedures and the complexity of patients undergoing grafts.…”

Management of Aortic Infections: Role of Open Surgery and the Value of Multidisciplinary Team Approach

“…Conversely, because the morbidity and mortality of graft explantation (or even lifelong antimicrobial therapy) are so great, a high degree of certainty is required in AGI diagnosis. Most clinical series on aortic graft infection and mycotic aneurysms have reported their diagnostic criteria as being a combination of 'clinical, radiological and microbiological' features but have always been vague about how these have been applied [15,27]. Historically, the way in which these three groups of factors should be combined has not been addressed, hindering conglomeration of data and precluding future trial design [5,[28][29][30][31].…”

Late Stent Graft Infection after the Emergency Endovascular Repair of a Secondary Iliac Artery-Enteric Fistula Treated with Graft Removal and In Situ Aortic Reconstruction Using Femoral Veins

“…With a growing number of patients being treated with stent grafts, the management of stent graft infections has recently been discussed in a similar way to graft infections following conventional open aneurysm repair. 10) In addition to adequate antibiotic therapy, the management of aortic graft infections consists of the removal of the infected graft and revascularization. Traditionally, revascularization has been accomplished via extra-anatomic bypass, usually axillobifemoral bypass, but due to the significant morbidity and mortality of this approach, in situ reconstruction with rifampicin-bonded grafts, cryopreserved allografts, or autologous FV grafts have been developed.…”