Management of Aortic Graft Infections and Mycotic Aneurysms: Improved Outcomes and Promising Early Results Through a Multidisciplinary Team Approach and In-situ Reconstruction Using Biological Conduits

Introduction: Aortic graft infection is fatal without device removal, but explantation is challenging as no device is designed to be removed. Like others, we previously reported 30% 30-day mortality with explantation and extraanatomical reconstruction. Here we report early results from a specialist team of explantation of abdominal grafts/endografts, and treatment of mycotic aneurysms, with in situ reconstruction using biological conduits. Methods: We report 19 consecutive patients with infected abdominal aortic grafts/endografts (16) or primary mycotic aneurysms (3) who presented between May 2015 and March 2018. Diagnosis was made via standardised criteria within a vascular infection MDM and all patients had follow up (mean 13 months) within a dedicated clinic with data being prospectively collected. Results: This series consists of 19 consecutive patients (mean age 69 (56-84), 15 men): 16 with aortic grafts and 3 with primary mycotic aortic pseudoaneurysms. 9 patients had previous EVAR and 7 had previous open repairs. 4 patients (21%) presented with aorto-enteric fistulae. All were treated with in-situ reconstruction using bovine pericardium (5/19), femoral veins (13/19) or composite biological conduits (1/19). There were 9 bifurcated grafts, 9 tube grafts and 1 composite uni-iliac conduit. Highest clamp position was supra-coeliac (N¼8), supra-renal (4) and inter/infrarenal (7). Median blood loss was 3.5 L, operative time 8 hours, and transfusion requirement 8 units packed red cells. Median postoperative ITU/HDU stay was 8 days, with a median length of hospital stay of 23 days. Mortality was 0 at 30 days, 1 at 6 months (5%) and 2/19 (11%) at 13 months. Both deaths were due to recurrent secondary aortic-enteric fistulae. Postoperative complications included acute kidney injury in 10 patients with only 4 requiring temporary renal dialysis; drainage of chest/abdominal collections (N¼3); pneumonia (3), MI (1), DVT/PE (1). 2 patients required reoperation for bleeding or anastomotic pseudoaneurysm formation. All 17 survivors underwent a standardized antimicrobial course, following which the median CRP was 5 and WCC 8, and antimicrobials were stopped. All survivors had postoperative follow-up 18F-FDG PET-CT scans which showed resolved or significantly improved uptake around the neoaorta. Conclusion: Abdominal endograft explantation and in-situ biological conduit reconstruction is feasible and may prove curative, allowing termination of antimicrobial therapy. Long-term follow-up and ongoing multidisciplinary care is essential.