Περίληψη:
Introduction: Aortic graft infection remains a considerable clinical
challenge, and it is unclear which variables are associated with adverse
outcomes among patients undergoing partial resection.
Methods: A retrospective, multi-institutional study of patients who
underwent partial resection of infected aortic grafts from 2002 to 2014
was performed using a standard database. Baseline demographics,
comorbidities, operative, and postoperative variables were recorded. The
primary outcome was mortality. Descriptive statistics, Kaplan-Meier (KM)
survival analysis, and Cox regression analysis were performed.
Results: One hundred fourteen patients at 22 medical centers in 6
countries underwent partial resection of an infected aortic graft.
Seventy percent were men with median age 70 years. Ninety-seven percent
had a history of open aortic bypass graft: 88 (77%) patients had
infected aortobifemoral bypass, 18 (16%) had infected aortobiiliac
bypass, and 1 (0.8%) had an infected thoracic graft. Infection was
diagnosed at a median 4.3 years post-implant. All patients underwent
partial resection followed by either extra-anatomic (47%) or in situ
(53%) vascular reconstruction. Median follow-up period was 17 months
(IQR 1, 50 months). Thirty-day mortality was 17.5%. The KM-estimated
median survival from time of partial resection was 3.6 years. There was
no significant survival difference between those undergoing in situ
reconstruction or extra-anatomic bypass (P = 0.6). During follow up,
72% of repairs remained patent and 11% of patients underwent major
amputation. On univariate Cox regression analysis, Candida infection was
associated with increased risk of mortality (HR 2.4; P = 0.01) as well
as aortoenteric fistula (HR 1.9, P = 0.03). Resection of a single graft
limb only to resection of abdominal (graft main body) infection was
associated with decreased risk of mortality (HR 0.57, P = 0.04), as well
as those with American Society of Anesthesiologists classification less
than 3 (HR 0.35, P = 0.04). Multivariate analysis did not reveal any
factors significantly associated with mortality. Persistent early
infection was noted in 26% of patients within 30 days postoperatively,
and 39% of patients were found to have any post-repair infection during
the follow-up period. Two patients (1.8%) were found to have a late
reinfection without early persistent postoperative infection. Patients
with any post-repair infection were older (67 vs . 60 years, P = 0.01)
and less likely to have patent repairs during follow up (59% vs. 32%,
P = 0.01). Patients with aortoenteric fistula had a higher rate of any
post-repair infection (63% vs . 29%, P < 0.01)
Conclusion: This large multi-center study suggests that patients who
have undergone partial resection of infected aortic grafts may be at
high risk of death or post-repair infection, especially older patients
with abdominal infection not isolated to a single graft limb, or with
Candida infection or aortoenteric fistula. Late reinfection correlated
strongly with early persistent postoperative infection, raising concern
for occult retained infected graft material.
Συγγραφείς:
Janko, Matthew
Hubbard, Grant
Woo, Karen
Kashyap, Vikram S.
and Mitchell, Megan
Murugesan, Arun
Chen, Lin
Gardner,
Rachel
Baril, Donald
Hacker, Robert I.
Szeberin, Zoltan and
ElSayed, Ramsey
Magee, Gregory A.
Motta, Fernando
Zhou, Wei
and Lemmon, Gary
Coleman, Dawn
Behrendt, Christian-Alexander and
Aziz, Faisal
Black, James H.
Tran, Kimberly
Dao, Allen and
Shutze, William
Garrett, H. Edward
De Caridi, Giovanni and
Patel, Rhusheet
Liapis, Christos D.
Geroulakos, George and
Kakisis, John
Moulakakis, Konstantinos
Kakkos, Starvos K. and
Obara, Hideaki
Wang, Grace
Stoecker, Jordan
Rheaume, Pascal
and Davila, Victor
Ravin, Reid
DeMartino, Randall
Milner,
Ross
Shalhub, Sherene
Jim, Jeffrey
Lee, Jason
Dubuis,
Celine
Ricco, Jean-Baptiste
Coselli, Joseph
Lemaire, Scott
and Fatima, Javairiah
Sanford, Jennifer
Yoshida, Winston and
Schermerhorn, Marc L.
Menard, Matthew
Belkin, Michael and
Blackwood, Stuart
Conrad, Mark
Wang, Linda
Crofts, Sara and
Nixon, Thomas
Wu, Timothy
Chiesa, Roberto
Bose, Saideep and
Turner, Jason
Moore, Ryan
Smith, Justin
Irshad, Ali
Hsu,
Jeffrey
Czerny, Martin
Cullen, Jonathan
Kahlberg, Andrea and
Setacci, Carlo
Joh, Jin Hyun
Senneville, Eric
Garrido, Pedro
and Sarac, Timur P.
Rizzo, Anthony
Go, Michael R.
Bjorck,
Martin
Gavali, Hamid
Wanhainen, Anders
D'Oria, Mario and
Lepidi, Sandro
Mastrorilli, Davide
Veraldi, Gianfranco and
Piazza, Michele
Squizzato, Francesco
Beck, Adam
St John,
Rebecca
Wishy, Andrew
Humphries, Misty
Shah, Samir K. and
Back, Martin
Chung, Jayer
Lawrence, Peter F.
Bath, Jonathan
and Smeds, Matthew R.
