REVIEW  THORACIC AORTIC CHALLENGES 

Italian Journal of Vascular and Endovascular Surgery 2020 March;27(1):85-92

DOI: 10.23736/S1824-4777.19.01430-X

Copyright © 2019 EDIZIONI MINERVA MEDICA

lingua: Inglese

Management of thoracic aortic graft infections

Kendal M. ENDICOTT ¹ ✉, Bradley TAYLOR ², Shahab TOURSAVADKOHI ¹

¹ Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD, USA; ² Division of Cardiovascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD, USA

Thoracic aortic graft infection is a rare but devastating and often fatal complication of aortic surgery. The “gold standard” of treatment is total graft explantation, wide local debridement, and vascular reconstruction. These operations are complicated by both aorto-esophageal fistulas (AEF) and aorto-bronchial fistulas (ABF). The purpose of this article is to review the current literature regarding the etiology and pathogenesis of thoracic aortic graft infections as well as discuss the options for surgical repair as well as outcomes. Prosthetic grafts utilized for thoracic aortic repair in both open and endovascular techniques are subject to bacterial contamination. Peri-operative contamination, hematogenous seeding, and mechanical erosion can infect thoracic aortic grafts which can lead to AEF and ABF. Staphylococcus and Streptococcus infections are most common however up to 30% of intraoperative cultures are negative. Clinical presentation can vary from subtle signs of failure-to-thrive to overt hemorrhage in the case of fistulization. Computed tomographic angiography (CTA) is the most informative diagnostic imaging modality. Management of infected thoracic aortic grafts traditionally involves complete excision of the infected graft, debridement, and vascular reconstruction with either extra-anatomic or in-situ reconstruction. In the case of AEF or ABF, initial endovascular placement of a thoracic endograft to control hemorrhage with subsequent fistula repair with and without endograft excision has been advocated. Other strategies involve endograft preservation with antibiotic therapy alone. Thoracic aortic graft infections are a complex surgical disease with high morbidity and mortality. While published data describes different treatment strategies and outcomes, there is no conclusive evidence for a definitive treatment strategy. Ongoing study is needed to understand the most effective treatment for this complex and morbid surgical disease.

KEY WORDS: Aortic diseases, surgery; Vascular grafting; Infections; Esophageal fistula