Systematic Review and Meta: Analysis of Aortic Graft Infections following Abdominal Aortic Aneurysm Repair

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Abstract

Introduction. Aortic graft infection (AGI) is a rare complication following AAA repair and is associated with high morbidity and mortality. Management is variable, and there are no evidence-based guidelines. The aim of this study was to systematically review and analyse management options for AGI.

Methods

Data was collected between July and August 2018. A full HDAS search was conducted on the following databases: MEDLINE, EMBASE, CINAHL, and PUBMED. Meta-analysis was conducted using RevMan 5 software.

Results

1,365 patient outcomes were assessed (10 cohort studies and 12 comparative studies). The most common treatment was in situ replacement of the graft (ISR) followed by extra-anatomical replacement (EAR). Various grafts were used for ISR, such as fresh/cryopreserved allograft, venous graft, and prosthetic grafts. No graft material was shown to be superior. Axillobifemoral graft was the commonest type of EAR used. In the majority of cohort studies, ISR was the main treatment for AGI. There was no significant difference in the overall mortality rate (ISR n = 70/176 vs. EAR n = 70/176 vs. EAR P = 0.87). Graft occlusion rate was significantly lower in the ISR group vs. the EAR group ( n = 70/176 vs. EAR n = 70/176 vs. EAR P = 0.87). Graft occlusion rate was significantly lower in the ISR group vs. the EAR group ( n = 70/176 vs. EAR n = 70/176 vs. EAR P = 0.87). Graft occlusion rate was significantly lower in the ISR group vs. the EAR group ( Discussion. In situ replacement is the preferred method of treatment as it had lower rates of occlusion. Further strong evidence is required, such as a multicentre trial to establish a management pathway for the condition.

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Most cited references 30

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Treatment and outcomes of aortic endograft infection.

Matthew R Smeds, Audra Duncan, Michael P Harlander-Locke … (2016)

This study examined the medical and surgical management and outcomes of patients with aortic endograft infection after abdominal endovascular aortic repair (EVAR) or thoracic endovascular aortic repair (TEVAR).

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The incidence and factors associated with graft infection after aortic aneurysm repair.

Rebecca Symons, Kara R. Vogel, David R Flum (2008)

The reported rate of abdominal aortic graft infections (AGIs) is low, but its incidence and associated factors have not been evaluated on a population level. We hypothesized that AGI occurs more often in patients with periprocedural nosocomial infections and less often after endovascular aneurysm repair (EVAR). A retrospective cohort study was done of all patients undergoing abdominal aortic aneurysm (AAA) repair (1987-2005) in Washington State by using the Comprehensive Hospital Abstract Reporting System (CHARS) data. Nosocomial infection was defined as one or more of pneumonia, urinary tract infections, blood stream septicemia, or surgical site infection at the index admission. Readmissions and reintervention for graft infections defined AGIs excluding the diagnostic code of renal failure or those who appeared to have dialysis grafts. Between 1987 and 2005, 13,902 patients (mean age, 71.3 +/- 8.8 years; 90.8% men) underwent AAA repair (12,626 open, 1276 EVAR). The cumulative rate of AGIs in the cohort was 0.44%. The 2-year rate of AGI was 0.19% among open vs 0.16% in EVAR (P = .75) and 0.2% in both elective and nonelective patients. Open procedures had greater rates of perioperative pneumonia (11.1% vs 2.4%, P < .001), blood stream septicemia (1.6% vs 0.7%, P < .01), and surgical site infection (.5% vs 0%, P < .012) compared with EVAR. When individually analyzed, blood stream septicemia (.93% vs 18%, P = .014) and surgical site infection (1.61% vs 0.19%, P = .01) were significantly associated with AGIs. The median time to AGI was 3.0 years, and AGI presented sooner (< or =1.4 years) if nosocomial infection occurred at the index admission. This risk of developing AGI after open repair was highest in the first postoperative year (32% of all AGI occurred in year 1). In an adjusted model, blood stream septicemia was significantly associated with AGI (odds ratio, 4.2; 95% confidence interval, 1.5-11.8) The incidence of AGI was low, presented most commonly in the first postoperative year, and was similar among patients undergoing open AAA repair and EAVR. Patients with nosocomial infection had an earlier onset of AGI. The 2-year rate of AGI was significantly higher in patients who had blood stream septicemia and surgical site infection in the periprocedural hospitalization. These data may be helpful in directing surveillance programs for AIG.

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Diagnosis and treatment of prosthetic aortic graft infections: confusion and inconsistency in the absence of evidence or consensus.

S F FitzGerald, C. Kelly, H Humphreys (2005)

Prosthetic aortic graft infections represent a major diagnostic and therapeutic challenge. Although a combination of clinical assessment, imaging and microbiological investigations is usually helpful, there are no agreed criteria to confirm a diagnosis. Potential pathogens isolated from superficial specimens may be misleading but influence the choice of antimicrobial agents. Removal of the infected material is strongly recommended. However, this is not always possible in the very debilitated or clinically unstable patient. The choice of which antimicrobial agents to administer as empirical or definitive therapy and the duration of treatment are unclear. A multi-disciplinary group is required to offer guidance, based on what evidence there is, and to provide expert consensus (as is the case for infective endocarditis) to optimize the management of these difficult infections.

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Author and article information

Contributors

O. S. Niaz:

ORCID: https://orcid.org/0000-0001-5715-7648

Journal

Journal ID (nlm-ta): Int J Vasc Med

Journal ID (iso-abbrev): Int J Vasc Med

Journal ID (publisher-id): IJVM

Title: International Journal of Vascular Medicine

Publisher: Hindawi

ISSN (Print): 2090-2824

ISSN (Electronic): 2090-2832

Publication date Collection: 2020

Publication date (Electronic): 31 January 2020

Volume: 2020

Electronic Location Identifier: 9574734

Affiliations

Department of Vascular Surgery, Princess Alexandra Hospital, Harlow CM20 1QX, UK

Author notes

Academic Editor: Bhagwan Satiani

Author information

O. S. Niaz https://orcid.org/0000-0001-5715-7648

A. Rao https://orcid.org/0000-0001-8728-8729

Article

DOI: 10.1155/2020/9574734

PMC ID: 7013324

PubMed ID: 32206352

SO-VID: c2a7a3f2-6dde-4d8b-b5cc-d1d67e253ee0

License:

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 4 September 2019

Date revision received : 23 December 2019

Date accepted : 7 January 2020

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