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INTRODUCTION: Limited single center experiences with the treatment of infected endovascular endografts (I-EVAR) have been reported. We performed a multicenter review of the surgical care of these patients to elucidate short and long term outcomes.
METHODS: A retrospective analysis of all EVAR explants from 2000 to 2014 at 4 institutions was performed. Patients with I-EVAR undergoing surgical treatment were reviewed. Data was obtained detailing pre-operative patient demographics, post-operative morbidity and mortality, and long term follow up.
RESULTS: 36 patients, 30 male (83%) and 6 female (17%), were treated with endovascular graft excision and revascularization for I-EVAR with a median age of 69 (range, 54-80 years). Average time from initial EVAR to explantation was 589 days (range, 43-2466 days). Pre-operative comorbidities include hypertension, 32 (89%), tobacco use, 31 (86%), coronary artery disease, 26 (72%), hyperlipidemia, 25 (69%), peripheral arterial disease, 13 (36%), cerebrovascular disease, 10 (28%), diabetes, 10 (28%), chronic obstructive pulmonary disease, 9 (25%), chronic kidney disease, 9 (25%). The most common presenting symptoms were leukocytosis in 23 (63%), pain in 21 (58%), and fever in 20 (56%), which were present an average of 22 days prior to explantation. 8 different types of endografts were removed. Three patients (8%) underwent emergency explantation. 32 patients underwent total graft excision (89%), while 4 patients underwent partial excision (11%). Methods of reconstruction included in situ reconstruction, 25 (69%) and extra-anatomic reconstruction 11 (31%). Conduits used in reconstruction consisted of Dacron +/- rifampin treatment, PTFE, cryopreserved allograft, and superficial femoral vein. 49 organisms grew from operative cultures. Gram positives were the most common isolate found in 32 (88%), including Staphylococcus (12, 33%), and Streptococcus (6, 17%). Anaerobes cultured in 11 (31%) patients, gram negatives in 8 (22%) patients and fungus in 5 (14%). A majority of patients were treated with long term suppressive antibiotic therapy, 21 (58%). Early complications included acute renal failure in 12 (33%), respiratory failure requiring tracheostomy in 3 (8%), bleeding in 2 (6%), sepsis in 2 (6%). 6 patients required reexploration due to hematoma, infected hematoma, lymphatic leak, small bowel perforation, open abdomen at initial operation, and anastomotic bleeding. Peri-operative mortality was 8% (3/36) and overall mortality was 25% (9/36) at a mean follow up of 402 days (range 0-2472 days). Type of reconstruction (in situ vs extra-anatomic) or conduit type did not affect peri-operative or overall mortality.
CONCLUSIONS: I-EVAR is a rare but potentially devastating clinical problem. Although peri-operative mortality is acceptable, overall mortality is high. The most common postoperative complication was acute renal failure, therefore aortic cross clamp time should be minimized. Although this is the largest series of I-EVAR, further studies will be necessary to understand risk factors and preventive measures.