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Ann Thorac Surg 1999;67:1990-1993
© 1999 The Society of Thoracic Surgeons

Management of thoracic aortic graft infections

^a Department of Surgery, Baylor College of Medicine, The Methodist Hospital, Houston, Texas, USA

Address reprint requests to Dr Coselli, 6560 Fannin, #1100, Houston, TX 77030
e-mail: jcoselli{at}bcm.tmc.edu

Presented at the Aortic Surgery Symposium VI, April 30–May 1, 1998, New York, NY.

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. We reviewed our experience managing patients with thoracic aortic graft infections to evaluate their clinical characteristics and outcomes of treatment.

Methods. Records of 20 consecutive patients with thoracic aortic graft infections managed over a 7 year period were retrospectively reviewed. Current follow-up status was obtained for all survivors.

Results. Nineteen patients (95%) underwent surgical treatment. Graft excision and in situ replacement were performed using Dacron grafts (10/19, 53%) or cryopreserved homografts (5/19, 26%). Three pseudoaneurysms were managed by debridement and primary repair. Although 30 day postoperative survival was 89% (17/19), in-hospital mortality occurred in 8 patients (42%). Infected thoracoabdominal aortic grafts were universally fatal. Of 6 patients with infected composite valve grafts, both patients who received new composite valve grafts died and all 4 who received homografts survived (p = 0.067).

Conclusions. Infections involving thoracic aortic grafts continue to carry a high mortality rate, especially in patients with polymicrobial infections, thoracoabdominal aortic graft infections, and composite valve graft infections. Use of homografts in the latter situation may improve outcome.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
The reported incidence of graft infections after thoracic aortic surgery ranges from 0.9% to 1.9% [1, 2]. While all vascular graft infections are associated with high morbidity and mortality, those involving the thoracic aorta are the most catastrophic, with reported mortality rates ranging from 25% to 75% [2, 3]. Due to anatomic considerations, extraanatomic bypass, the cornerstone of management for infected vascular grafts, is often unrealistic for thoracic aortic graft infections. By necessity, the surgical options usually involve either in situ graft replacement and/or preservation of the existing graft. Both approaches leave graft material where it is vulnerable to recurrent infection. Therefore, additional strategies are utilized to prevent recurrence: use of viable tissue flaps to obliterate dead space and provide vascularized coverage of the graft; placement of perigraft catheters for postoperative mediastinal antibiotic irrigation; use of cryopreserved homografts; and lifelong suppressive antibiotic therapy. The purpose of this retrospective review of our recent experience managing thoracic aortic graft infections is to evaluate the clinical characteristics of this complication and the outcome of this multifaceted treatment approach.

	Material and methods

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The medical records of 20 consecutive patients who underwent treatment for thoracic aortic graft infections between 1990 and 1997 were retrospectively reviewed. In all cases infection of a prosthetic thoracic aortic graft had been confirmed by preoperative or intraoperative cultures. Data collected included the original operation and any related complications; the manifestations of the graft infection at presentation; the pathogens identified; the interval between the initial operation and subsequent treatment; and morbidity and mortality related to the latter treatment. Follow-up was obtained via telephone or written correspondence with each patient or his primary physician. The mean length of follow-up was 3.4 years (range, 0.3–6.25 years).

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Presenting manifestations and diagnosis
Thirteen men and 7 women underwent thoracic aortic operations an average of 31.6 months (range, 1 month to 15 years; median, 10 months) prior to subsequent presentation and treatment for graft infection (Tables 1 and 2).

Surgical treatment
Thoracic aortic graft infections were treated surgically in 19 patients (95%). Existing grafts were excised and replaced in situ with new Dacron grafts after extensive debridement of involved mediastinal and chest wall tissue in 10 of the 19 operations (53%), including 2 involving replacement of infected composite valve grafts (CVGs). Cryopreserved homografts were used to replace infected CVGs in 4 patients and an ascending aortic graft in 1 patient. In an effort to minimize the amount of reconstruction required, partial graft excision was utilized for longer grafts provided that the graft was patent and the infection appeared to be localized to a limited portion of the graft. Similarly, while large pseudoaneurysms were treated by excision and graft replacement (4 patients), small pseudoaneurysms were managed by primary graft repair after debridement (3 patients). One patient had undergone a right axillo-femoral bypass prior to referral for treatment of an infected descending thoracic aortic graft with a pseudoaneurysm. The infected graft was excised and the proximal and distal aortic stumps were oversewn without reconstruction. Additional procedures employed in these patients included coverage of the involved graft with a pedicled omental flap in 9 patients (47%) and occasional placement of perigraft catheters for postoperative mediastinal antibiotic irrigation.

Culture results and medical treatment
Preoperative identification of pathogens was accomplished in 12 patients (60%) via cultures of serial blood samples, wound drainage, or perigraft fluid obtained under CT guidance. Intraoperative cultures, obtained from graft material or surrounding tissue, were positive in 18 patients (90%). Infection with Staphylococcus aureus was present in 9 patients (45%), making it the most commonly identified organism. Polymicrobial graft infections were documented in 4 patients (20%). In all cases, broad-spectrum antibiotics were administered initially and were subsequently adjusted based on culture results. After receiving parenteral antibiotics for 4 to 6 weeks, patients were placed on lifelong suppressive oral antibiotic therapy.

The one patient treated with medical therapy alone presented with symptomatic pseudomonal bacteremia. Fluid adjacent to the proximal aortic graft was identified on CT scan. Aortography confirmed graft patency and did not reveal any evidence of pseudoaneurysm. Nonoperative management was continued in light of the patient’s marked clinical improvement on parenteral antibiotic therapy.

Early mortality and morbidity
The results of treatment are detailed in Tables 1 and 2. Although 17 patients (89%) who underwent operation survived 30 days, 6 additional patients died during the initial hospitalization; therefore, early mortality occurred in 8 patients (42%). Multiple organ failure following sepsis was the leading cause of mortality. All 3 patients with infected thoracoabdominal grafts, including 1 with chronic paraparesis following the initial operation, developed paraplegia and died. Polymicrobial graft infections were fatal in 3 of 4 cases (75%). Of the 6 patients with infected CVGs, all 4 patients who received homografts survived; in contrast, both patients who received new mechanical CVGs died during the hospitalization (p = 0.067, Fisher exact test).

Mediastinal reexploration was required for postoperative bleeding in 2 patients. One of these patients also underwent operation for acute gastrointestinal bleeding due to ulcer disease. One patient required repair of a ruptured iliac artery aneurysm. Delayed wound healing was observed in 3 of the patients.

Long-term follow-up
Among the 11 patients who were discharged following operation, there have been 2 (18%) late deaths (Table 1). Infection has not recurred in any of the 10 living patients, including the patient managed nonoperatively. All patients report faithful continuation of their oral antibiotic regimens.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Well established principles regarding definitive management of prosthetic vascular graft infections include: wide debridement of infected tissues, including the involved vessel wall; local coverage with viable tissue such as omentum or muscle flaps; placement of drains; long-term antibiotic administration; and graft excision with extraanatomic rerouting of the arterial blood flow [2–7]. Adherence to the latter principle, however, is not practical in most cases of thoracic aortic graft infection. Although the in situ replacement of an infected aortic graft with a new graft can be successful, the early mortality remains high [1–3, 5, 8]. Contributing to the high surgical risk is the need for aggressive debridement in an inflamed field containing postoperative adhesions and necrotic tissue, resulting in a prolonged operation with substantial blood loss. Additionally, these patients often present in poor condition and may require an emergency operation in cases complicated by persistent sepsis, hemorrhage, or ischemia.

Infections involving CVGs remain particularly ominous. Composite valve graft endocarditis is the most common late complication following aortic root replacement in patients with Marfan syndrome, occurring in 4% of cases and carrying a 50% mortality rate [9]. Our experience suggests that the use of cryopreserved homografts may improve the outcome of this catastrophic problem. Despite the extremely small number of patients, the difference in early mortality between those receiving prosthetic CVGs (2/2, 100%) and those receiving homografts (0/4) approached statistical significance (p = 0.067). Our current practice is to use cryopreserved homografts for replacement of infected CVGs whenever possible. The reported eradication of infection when homografts are used as replacement conduits, even in the presence of virulent organisms, attests to their resistance to infection [10–12]. Furthermore, the use of homografts may limit the extent of debridement required at the infection site. The use of homografts for infected graft replacement in more distal aortic segments may provide similar advantages.

Finally, the lifelong need for appropriate parenteral antibiotic prophylaxis in all patients with prosthetic aortic grafts who are undergoing procedures that cause bacteremia cannot be overemphasized [7]. Our series confirms that the potential for graft infection continues long after the original operation. Eight of the patients (40%) presented 2 or more years after their initial operation. The wide variety of pathogens demonstrated above is typical of graft infections and mandates the use of broad-spectrum antibiotics. The catastrophic nature of an infected aortic graft justifies this meticulous approach to prevention.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Joseph S. Coselli Scott A. LeMaire Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Coselli, J. S. Articles by LeMaire, S. A. Search for Related Content PubMed PubMed Citation Articles by Coselli, J. S. Articles by LeMaire, S. A.