Systematic approach to diagnosis and management of infected prosthetic grafts in the proximal aorta

Abstract

Objectives: Management of infected prosthetic aortic grafts in the ascending and or root is complex and multifaceted. We report our diagnostic pathway, management and outcomes, identifying successful strategies. Methods: This was a retrospective, single center, observational study. Consecutive patients who underwent management of infected aortic grafts in the ascending and/or root at our institution between October 1998 and December 2019 were included. The main outcome measures were: discharge from hospital alive with at least 1 year survival, operative mortality and success of primary treatment strategy. Results: Twenty-six patients presented with infection of proximal aortic grafts and were managed through a number of strategies with an overall hospital-survival of 81% and 1 year survival of 69%. Twenty of them ultimately underwent redo surgery with 25% operative mortality (within 24 h of surgery). Five patients underwent washout and irrigation of which two were successfully treated and cured with adjunctive antibiotics and two went on to have staged explant and definitive surgery. Interval between surgery and infection was 42.5 ± 35.8 months. All patients had at least one major criterion and three minor criterions with no diagnostic uncertainty. The commonest primary strategy was 3a (definitive surgery), (13/26, 50%). Conclusions: Adopting a systematic and flexible patient specific approach to the diagnosis and management of patients with proximal aortic graft infections results in reasonable overall 1 year survival. In the majority of patients surgery is ultimately required in an attempt to achieve a curative treatment; however this comes with high operative mortality risk.

Robotic-assisted closed-chest management of a fungal-infected prosthetic aortic graft: a case report

“…Lyons and associates suggested guidelines to assist in establishing the diagnosis of prosthetic graft infection, based on clinical, radiological, and laboratory findings [ 13 ]. Recent literature suggests that most patients with an infected aortic graft tend to present with at least some clinical evidence of sepsis [ 14 ], but this was not the case in our patient, in which the periaortic collection was an incidental radiologic finding after he was hit in the chest wall by a car door. Our patient’s fluid cultures yielded Aspergillus , another unusual finding because the most common infectious agents in these cases, as previously alluded to, are Gram-positive bacteria, typically Staphylococcus aureus [ 15 ].…”

Role of Multimodal Imaging in Patients With Suspected Infections After the Bentall Procedure

“…Although the ideal treatment of an infection after the Bentall procedure consists in the redo of the Bentall root when the thoracic aortic prosthesis is involved (it occurs in about 2% of cases) ( 9 – 11 ), it is really challenging. Indeed, the replacement of the infected graft is burdened by a high mortality ( 5 , 11 ), particularly in the case of long-lasting infections or severe comorbidities. Alternative strategies comprise aggressive debridement and irrigation (i.e., graft salvage) and conservative medical treatment (i.e., antibiotics) ( 5 , 12 ).…”

“…Indeed, the replacement of the infected graft is burdened by a high mortality ( 5 , 11 ), particularly in the case of long-lasting infections or severe comorbidities. Alternative strategies comprise aggressive debridement and irrigation (i.e., graft salvage) and conservative medical treatment (i.e., antibiotics) ( 5 , 12 ). The lack of evidences about the best treatment option determines a controversial management of these patients.…”

The perils of diagnosing and managing aortic root prosthetic graft infection

“…One strategy that can be utilized for diagnosing ARGI and proximal aortic infections may be the use of a combination of the modified Duke's criteria and the Management of Aortic Graft Infection collaboration (MAGIC) guidelines for vascular graft infections. 5 Potential complications of infection include sepsis, fistula formation and bleeding, and the prevention of these complications is essential to reduce morbidity and mortality. Patients presenting with signs of sepsis or systemic inflammation should be treated with broad-spectrum antibiotics promptly, and blood cultures should be taken.…”

“…Instead, diagnosis is usually made through a combination of clinical examination, laboratory markers, and radiological investigations. One strategy that can be utilized for diagnosing ARGI and proximal aortic infections may be the use of a combination of the modified Duke's criteria and the Management of Aortic Graft Infection collaboration (MAGIC) guidelines for vascular graft infections 5 …”