The purpose of this study was to evaluate survival and freedom from reinfection of patients with infected native aortic aneurysms (INAA) managed with in situ revascularization (ISR), either with open surgical repair (OSR) or endovascular aneurysm repair (EVAR), and identify outcome predictors.
Patients with INAA who underwent ISR between January 2005 and December 2020 were included in this retrospective single-center study. The diagnosis of INAA consisted of a combination of two or more of the following criteria: (1) clinical presentation, (2) laboratory results, (3) imaging, (4) intraoperative findings. The primary endpoint was 30-day mortality; secondary endpoints were in-hospital mortality, estimated survival, patency, and freedom from reinfection using the Kaplan-Meier method. Predictive factors for adverse outcomes were searched for using Mann-Whitney or Fisher’s Exact Test and multivariate Cox regression analysis.
Sixty-five patients (53 men (81.5%); median age 69.0 years [IQR: 61.5-75.0]) were included, of whom 31 (47.7%) were immunocompromised. Sixty patients were symptomatic (92.3%), and 32 (49.2%) presented with rupture including 3 aortocaval fistulae (4.6%) and 12 aorto-enteric fistulae (18.5%). The most common location was infra-renal (n=39; 60.0%). Fifty-five patients (84.6%) underwent primary OSR with ISR, 3 (4.6%) required EVAR as a bridge to OSR and 8 (12.3%) EVAR as definitive treatment. The approach was most often a midline laparotomy (n=44; 67.7%), reconstruction and aorto-aortic bypass (n=28; 40.6%) and use of a silver & 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). Median follow-up was 33.5 months (IQR:13.6-62.3). The estimated 1- and 5-year survival rates were 79.7% (95%CI: 67.6-87.7) and 67.4% (95%CI: 51.2-79.3); freedom from reinfection was 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). Reinfection increased with operating time (p=.009).
Selective use of ISR and OSR, in combination with targeted antimicrobial therapy functions reasonably well in the setting of INAA, though larger, prospective, multicenter studies with appropriately powered comparative cohorts would be necessary to confirm this finding and determine the best vascular substitute and the precise role of EVAR as a “bridge” to OSR or definitive treatment.

Copyright © 2021. Published by Elsevier Inc.