Thoracic and Abdominal Aortic Infections: A Multidisciplinary Team Approach Using Standardized Protocols and In Situ Biologic Neoaortic Reconstruction; Midterm Outcomes

Objective: The objective was to report and to evaluate the midterm outcomes of aortic infections in a high-volume center using a multidisciplinary team standardized management protocol. Methods: A retrospective analysis was conducted of prospectively collected data of 40 aortic infection cases (primary mycotic aneurysm or infected aortic grafts) managed between 2014 and 2019. All patients were managed as part of a multidisciplinary dedicated aortic infection service by complete resection of infected aortic segment or infected graft with in situ reconstruction using biologic graft. All patients completed a minimum of 3 months postoperative antimicrobial treatment. Curative state was defined by clinical assessment, normal inflammatory markers (white blood cell count, C-reactive protein), and resolution of uptake on positron emission tomography scan (maximum standardized uptake <4) at least 1 month after completion of antimicrobial treatment. Results: Since 2015 at our center, 40 aortic infection (primary or after explantation) reconstructions have been performed with no intraoperative mortality (2.5% at 30 days and 17.5% at 6 months). Overall survival was 75% (mean follow-up, 26 months). All cases were reconstructed with in situ biologic grafts (19 bovine, 18 autologous vein, 2 bovine-vein combinations, and 1 cadaveric allografts), including 6 thoracic, 4 thoracoabdominal, and 30 abdominal. Median age at time of reconstruction was 70 years (range, 40-84 years) in a predominantly male (33) cohort. There were 14 (35%) patients who presented with primary infected (mycotic) aneurysms, 4 (29%) of which underwent immediate open intended-curative reconstruction; 10 (71%) were temporized with endovascular stenting followed by open reconstruction. The remaining 26 (65%) cases represented secondary infection of 11 (28%) endovascular stent grafts and 15 (38%) previous open graft repairs. Sixteen (40%) cases of aortoenteric fistulization were identified. Eight (80%) deaths were related to complications of surgery, initial infection, or reinfection, and two were from unrelated causes. Median time to death was 44 days (interquartile range, 39-186 days), and no significant difference was found between mortality in bovine vs autologous vein reconstructions on logrank (Mantel-Cox) testing (P ¼ .33). Twenty-six patients (65%) have reached a curative state to date. Reinfection occurred in three (8%) cases, two of which had undergone further intervention with additional stenting or intra-abdominal surgery. The most common cause of initial infection was an aortoenteric fistula, identified in 16 (40%) cases. Conclusions: Complete excision of infected aortic graft or native aorta combined with biologic neoaorta reconstruction is technically challenging but can be curative without the need of long-term antimicrobials. In our experience a multidisciplinary team approach and dedicated service seem to improve outcomes.