Outcomes after Operative Management of Suprarenal and Thoracoabdominal Aortic Infections
Erik M Anderson, Scott T Robinson, Brian J Fazzone, Christopher R Jacobs, Michol A Cooper, Zain Shahid, Gilbert R Upchurch, Jr., Martin R Back, Salvatore T Scali, Thomas S Huber
University of Florida, Gainesville, FL
Background: Outcomes after operative management of suprarenal and thoracoabdominal aortic infections are poorly characterized due to their rare presentation and high morbidity and mortality. Surgical treatment is more complex than isolated infrarenal aortic infection, frequently involving excisional debridement of infected tissues, extirpation of native aortic or prosthetic material, and revascularization of renal/mesenteric vessels, as well as the lower extremities. Herein, our experience with the surgical management of suprarenal and thoracoabdominal aortic infections is reported.
Methods: A single-center retrospective review of consecutive patients who underwent operations for primary and secondary suprarenal or thoracoabdominal aortic infections from 2002-2021 was performed. Isolated thoracic, juxtarenal, and infrarenal aortic infections, as well as aortic infections managed with medical or endovascular therapy were excluded. The primary end-point was 30-day mortality. Secondary end-points included complications, recurrent/persistent infection, and 1-year survival. A subgroup analysis was performed to compare primary(e.g. mycotic aneurysms[MA]) and secondary(e.g. graft infections[GI]) aortic infections.
Results: 56 patients with suprarenal(n=22) and thoracoabdominal(n=34) aortic infections were included. Mean age was 65±13 years and a majority were male(79%, n=44)(Table1). 57%(n=32) presented with rupture, and 20%(n=11) involved an aorto-enteric fistula(AEF). S. aureus was the most commonly isolated organism(29%, n=16) from blood or intra-operative cultures. In situ aortic reconstruction was performed using antibiotic-soaked prosthetic graft(75%, n=42), cadaveric allograft(7%, n=4), or femoral-popliteal vein(5%, n=3). Extra-anatomic bypass with aortic ligation was performed in 14%(n=8). An antegrade approach was the preferred method of renal/visceral revascularization(77%, n=43). Mean target vessels revascularized was 2.1±1.3 including 67-renal, 30-SMA, and 15-celiac artery bypasses. The preferred conduit for renal/visceral bypass was prosthetic graft while vein conduit was used in 4%(n=2/46). Renal and/or mesenteric vessel ligation occurred in 36%(n=20). Overall 30-day mortality was 16%(n=9) including 2 intraoperative deaths(4%). All surviving patients received an extended course of parenteral antibiotics, and 35(63%) were continued on lifelong oral suppressive therapy. Major complications included renal failure(20%, n=11), hemorrhage(16%, n=9), respiratory failure(14%, n=8) and graft thrombosis(9%, n=5). 5%(n=3) had documented clinical persistence/recurrence of infection. Compared to GI, MAs were more likely to present ruptured(76% vs. 37%, p=0.008) but less likely to have concurrent AEF(3% vs. 37%, p=0.005). MAs were more commonly repaired with in situ prosthetic graft(83% vs. 67%) and required more renal/visceral reconstructions(2.5±1.4 vs. 1.7±1.2, p=0.02). Outcomes were similar between primary and secondary aortic infections, including 1-year survival(MA:58±10% vs. GI:66±9%;log-rank p=0.9) and freedom from reintervention(MA:51±10% vs. GI:60±10%;log-rank p=0.5)(Figure1).
Conclusions: Suprarenal and thoracoabdominal aortic infections are rare and operative management results in significant morbidity but acceptable perioperative mortality. Distinct phenotypes between primary and secondary infection are identified that impact patient presentation and operative decision-making. Using a complementary approach to reconstruction configuration and conduit choice can lead to comparable results for different infectious indications; however, reintervention is common underscoring the need for surveillance postoperatively.
Table1.
| Variable, No. (%) | All PatientsN=56 (100%) | Mycotic Aneurysm N=29 (52%) | Graft Infection N=27 (48%) | p-value | ||
| Demographics | ||||||
| Age (years, mean±SD) | 65±13 | 63±12 | 67±13 | 0.3 | ||
| Male sex | 44 (79%) | 24 (83%) | 20 (74%) | 0.6 | ||
| Race | 0.9 | |||||
| -White | 43 (77%) | 23 (79%) | 20 (74%) | |||
| -Black | 9 (16%) | 4 (14%) | 5 (19%) | |||
| Comorbidities | ||||||
| BMI (mean±SD) | 25±6 | 26±6 | 25±5 | 0.6 | ||
| Smoking | 0.2 | |||||
| -Active | 18 (32%) | 12 (41%) | 6 (22%) | |||
| -Former | 14 (25%) | 5 (17%) | 9 (33%) | |||
| Diabetes Mellitus | 15 (27%) | 10 (34%) | 5 (19%) | 0.3 | ||
| COPD | 10 (18%) | 5 (17%) | 5 (19%) | 1 | ||
| Coronary Artery Disease | 23 (41%) | 12 (41%) | 11 (41%) | 1 | ||
| Hypertension | 41 (73%) | 22 (76%) | 19 (70%) | 0.9 | ||
| Heart Failure | 7 (13%) | 3 (10%) | 4 (15%) | 0.9 | ||
| Kidney Disease | 16 (29%) | 9 (31%) | 7 (26%) | 0.9 | ||
| Peripheral Arterial Disease | 9 (16%) | 2 (7%) | 7 (26%) | 0.1 | ||
| Immunocompromised | 7 (13%) | 6 (21%) | 1 (4%) | 0.1 | ||
| Intravenous Drug Use | 3 (5%) | 3 (10%) | 0 (0%) | 0.3 | ||
| Presentation | ||||||
| Symptomatic | 53 (95%) | 28 (97%) | 25 (93%) | 1 | ||
| Rupture | 32 (57%) | 22 (76%) | 10 (37%) | 0.008* | ||
| Aorto-enteric fistula | 11 (20%) | 1 (3%) | 10 (37%) | 0.005* | ||
| Operative Details | ||||||
| Aortic Repair/Ligation | 0.02* | |||||
| -Extra-anatomic Bypass with Aortic Ligation | 8 (14%) | 1 (3%) | 7 (26%) | |||
| -ISR with Antibiotic-Soaked | 42 (75%) | 24 (83%) | 18 (67%) | |||
| Prosthetic Graft | ||||||
| -ISR with Cadaveric Graft | 4 (7%) | 2 (22%) | 2 (7%) | |||
| -Femoral-popliteal Vein | 3 (5%) | 0 (0%) | 3 (11%) | |||
| Visceral Reconstruction | 0.2 | |||||
| -Antegrade Debranching/ Reimplantation | 43 (77%) | 20 (69%) | 23 (85%) | |||
| -Retrograde Debranching | 3 (5%) | 3 (10%) | 0 (0%) | |||
| Vessels Bypassed (mean±SD) | 2.1±1.3 | 2.5±1.4 | 1.7±1.2 | 0.02* | ||
| -Celiac | 15 (27%) | 11 (38%) | 4 (15%) | 0.1 | ||
| -SMA | 30 (54%) | 20 (69%) | 10 (37%) | 0.03* | ||
| -R Renal | 28 (50%) | 17 (59%) | 11 (41%) | 0.3 | ||
| -L Renal | 39 (70%) | 19 (66%) | 20 (74%) | 0.7 | ||
| Vessels Ligated (mean±SD) | 0.5±0.7 | 0.5±0.7 | 0.4±0.6 | 0.7 | ||
| Outcomes | ||||||
| Length of Stay (days, mean±SD) | 24±20 | 23±16 | 25±24 | 0.7 | ||
| Persistent Infection/ Reinfection | 3 (5%) | 1 (3%) | 2 (7%) | 1 | ||
| Hemorrhage | 9 (16%) | 5 (17%) | 4 (15%) | 1 | ||
| Graft Thrombosis | 5 (9%) | 1 (3%) | 4 (15%) | 0.3 | ||
| Anastomotic Stenosis | 3 (5%) | 1 (3%) | 2 (7%) | 0.9 | ||
| Renal Failure | 11 (20%) | 6 (21%) | 5 (19%) | 1 | ||
| Pulmonary Insufficiency | 8 (14%) | 3 (10%) | 5 (19%) | 0.6 | ||
| Bowel Ischemia/Leak | 3 (5%) | 1 (3%) | 2 (7%) | 0.9 | ||
| Deep Space Infection | 4 (7%) | 1 (3%) | 3 (11%) | 0.6 | ||
| Spinal Cord Ischemia | 4 (7%) | 4 (14%) | 0 (0%) | 0.07 | ||
| Myocardial Infarction | 2 (4%) | 2 (7%) | 0 (0%) | 0.5 | ||
| 30-day mortality | 9 (16%) | 5 (7%) | 4 (15%) | 1 | ||
| 90-day mortality | 12 (21%) | 6 (21%) | 6(22%) | 1 | ||
| Follow up (months, median [IQR]) | 3.0 [0.9,16.1] | 1.4 [0.7,4.5] | 9.0 [1.3,18.0] | 0.06 | ||
Figure1.
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