In-situ Bypass Is Associated with Superior Infection-free Survival Compared to Extra-Anatomic Bypass for the Management of Secondary Aortic Graft Infections Without Enteric Involvement. Journal of vascular surgery Janko, M. R., Hubbard, G., Back, M., Shah, S. K., Pomozi, E., Szeberin, Z., DeMartino, R., Wang, L. J., Crofts, S., Belkin, M., Davila, V. J., Lemmon, G. W., Wang, S. K., Czerny, M., Kreibich, M., Humphries, M. D., Shutze, W., Joh, J. H., Cho, S., Behrendt, C., Setacci, C., Hacker, R. I., Sobreira, M. L., Yoshida, W. B., D'Oria, M., Lepidi, S., Chiesa, R., Kahlberg, A., Go, M. R., Rizzo, A. N., Black, J. H., Magee, G. A., Elsayed, R., Baril, D. T., Beck, A. W., McFarland, G. E., Gavali, H., Wanhainen, A., Kashyap, V. S., Stoecker, J. B., Wang, G. J., Zhou, W., Fujimura, N., Obara, H., Wishy, A. M., Bose, S., Liang, P., Schermerhorn, M., Conrad, M. F., Hsu, J. H., Patel, R., Lee, J. T., Liapis, C. D., Moulakakis, K. G., Farber, M. A., Motta, F., Ricco, J., Bath, J., Coselli, J. S., Aziz, F., Coleman, D. M., Davis, F. M., Fatima, J., Irshad, A., Shalhub, S., Zhang, Q., Lawrence, P. F., Woo, K., Chung, J. 2022


OBJECTIVE: The optimal revascularization modality following complete resection of aortic graft infection (AGI) without enteric involvement remains unclear. The purpose of this investigation is to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients undergoing complete excision of AGI.METHODS: A retrospective, multi-institutional study of AGI from 2002-2014 was performed using a standardized database. Baseline demographics, comorbidities, and perioperative variables were recorded. The primary outcome was infection-free survival. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariable analyses were performed.RESULTS: 241 patients at 34 institutions from 7 countries presented with AGI during the study period (median age 68 years; 75% male). The initial aortic procedures that resulted in AGI were 172 surgical grafts (71%) and 66 endografts (27%) and 3 unknown (2%). 172 (71%) of the patients underwent complete excision of infected aortic graft material followed by in situ (in-line) bypass (ISB), including antibiotic-treated prosthetic graft (35%), autogenous femoral vein (NAIS) (24%), and cryopreserved allograft (41%). 69 patients (29%) underwent extra-anatomic bypass (EAB). Overall median Kaplan-Meier (KM) estimated survival was 5.8 years. Perioperative mortality was 16%. When stratified by ISB versus EAB, there was a significant difference in KM estimated infection-free survival (2910 days, IQR 391, 3771 versus 180 days, IQR 27, 3750 days; p<0.001). There were otherwise no significant differences in presentation, comorbidities, nor perioperative variables. Multivariable Cox regression showed lower infection-free survival among patients with EAB (HR 2.4, 95% CI 1.6-3.6; p<0.001), polymicrobial infection (HR 2.2, 95% CI 1.4-3.5; p=0.001), MRSA infection (HR 1.7, 95% CI 1.1-2.7; p=0.02), as well as the protective effect of omental/muscle flap coverage (HR 0.59, 95% CI 0.37-0.92; p=0.02).CONCLUSIONS: After complete resection of AGI, perioperative mortality is 16% and median overall survival is 5.8 years. EAB is associated with nearly a two-and-half fold higher re-infection/mortality compared to ISB. Omental and/or muscle flap coverage of the repair appear protective.

View details for DOI 10.1016/j.jvs.2022.03.869

View details for PubMedID 35470015