Fifteen-year, single-center experience with in situ reconstruction for infected native aortic aneurysms

• Published in: Journal of vascular surgery 2022-03, Vol.75 (3), p.950-961.e5
• Main Authors: Berard, Xavier, Battut, Anne-Sophie, Puges, Mathilde, Carrer, Mathilde, Stenson, Katherine, Cazanave, Charles, Stecken, Laurent, Caradu, Caroline, Ducasse, Eric
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Aneurysm; Aneurysm, Infected - diagnostic imaging; Aneurysm, Infected - microbiology; Aneurysm, Infected - mortality; Aneurysm, Infected - surgery; Anti-Bacterial Agents - therapeutic use; Aortic Aneurysm - diagnostic imaging; Aortic Aneurysm - microbiology; Aortic Aneurysm - mortality; Aortic Aneurysm - surgery; Aortic rupture; Aortitis; Aortoenteric fistula; Blood Vessel Prosthesis Implantation - adverse effects; Blood Vessel Prosthesis Implantation - mortality; Endovascular Procedures - adverse effects; Endovascular Procedures - mortality; Female; Hospital Mortality; Humans; Infected native aortic aneurysm; Male; Middle Aged; Mycotic aneurysm; Reinfection; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2021.08.094

The purpose of the present study was to evaluate the survival and freedom from reinfection for patients with infected native aortic aneurysms (INAAs) treated with in situ revascularization (ISR), using either open surgical repair (OSR) or endovascular aneurysm repair (EVAR), and to identify the predictors of outcome. Patients with INAAs who had undergone ISR from January 2005 to December 2020 were included in the present retrospective single-center study. The diagnosis of INAAs required a combination of two or more of the following criteria: (1) clinical presentation, (2) laboratory results, (3) imaging findings, and (4) intraoperative findings. The primary endpoint was 30-day mortality. The secondary endpoints were in-hospital mortality, estimated survival, patency, and freedom from reinfection using the Kaplan-Meier method. The predictive factors for adverse outcomes were evaluated using the Mann-Whitney U test or the Fisher exact test and multivariate regression analysis. A total of 65 patients (53 men [81.5%]; median age, 69.0 years; interquartile range, 61.5-75.0 years) were included, 31 (47.7%) were immunocompromised, 60 were symptomatic (92.3%), and 32 (49.2%) had presented with rupture, including 3 aortocaval fistulas (4.6%) and 12 aortoenteric fistulas (18.5%). The most common location was infrarenal (n = 39; 60.0%). Of the 65 patients, 55 (84.6%) had undergone primary OSR with ISR, 3 (4.6%) had required EVAR as a bridge to OSR, and 8 (12.3%) had undergone EVAR as definitive treatment. The approach was a midline laparotomy for 44 patients (67.7%), mostly followed by reconstruction and aortic–aortic bypass (n = 28; 40.6%) and the use of a silver and triclosan Dacron graft (n = 30; 43.5%). Causative organisms were identified in 55 patients (84.6%). The 30-day and in-hospital mortality rates were 6.2% (n = 4) and 10.8% (n = 7). The median follow-up was 33.5 months (interquartile range, 13.6-62.3 months). The estimated 1- and 5-year survival rates were 79.7% (95% confidence interval [CI], 67.6%-87.7%) and 67.4% (95% CI, 51.2%-79.3%). The corresponding freedom from reinfection rates were 92.5% (95% CI, 81.1%-97.1%) and 79.4% (95% CI, 59.1%-90.3%). On multivariate analysis, in-hospital mortality increased with uncontrolled sepsis (P < .0001), rapidly expanding aneurysms (P = .008), and fusiform aneurysms (P = .03). The incidence of reinfection increased with longer operating times (P = .009). The selective use of ISR and OSR combined with targeted antim