Semi-Conservative Treatment Versus Radical Surgery in Abdominal Aortic Graft and Endograft Infections

Hamid Gavali; Kevin Mani; Mia Furebring; Karl Wilhelm Olsson; David Lindström; Karl Sörelius; Birgitta Sigvant; Gustav Torstensson; Manne Andersson; Claes Forssell; Håkan Åstrand; Tobias Lundström; Shahzad Khan; Björn Sonesson; Otto Stackelberg; Peter Gillgren; Jon Isaksson; Björn Kragsterman; Khatereh Djavani Gidlund; Tal Horer; Mitra Sadeghi; Anders Wanhainen

doi:10.1016/j.ejvs.2023.06.019

Semi-Conservative Treatment Versus Radical Surgery in Abdominal Aortic Graft and Endograft Infections

Eur J Vasc Endovasc Surg. 2023 Sep;66(3):397-406. doi: 10.1016/j.ejvs.2023.06.019. Epub 2023 Jun 23.

Authors

Hamid Gavali¹, Kevin Mani², Mia Furebring³, Karl Wilhelm Olsson², David Lindström², Karl Sörelius⁴, Birgitta Sigvant⁵, Gustav Torstensson⁶, Manne Andersson⁷, Claes Forssell⁸, Håkan Åstrand⁹, Tobias Lundström¹⁰, Shahzad Khan¹¹, Björn Sonesson¹¹, Otto Stackelberg¹², Peter Gillgren¹³, Jon Isaksson¹⁴, Björn Kragsterman¹⁵, Khatereh Djavani Gidlund¹⁶, Tal Horer¹⁶, Mitra Sadeghi¹⁶, Anders Wanhainen¹⁷

Affiliations

¹ Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden. Electronic address: hamid.gavali@surgsci.uu.se.
² Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.
³ Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden.
⁴ Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
⁵ Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Vascular Surgery, Karlstad Central Hospital, Karlstad, Sweden.
⁶ Department of Surgery, Helsingborg Regional Hospital, Helsingborg, Sweden.
⁷ Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Surgery, County Hospital Ryhov, Ryhov, Jönköping County, Sweden.
⁸ Department of Cardiovascular Surgery, Division of Vascular Surgery, Linköping University Hospital, Linköping, Sweden.
⁹ Department of Surgery, County Hospital Ryhov, Ryhov, Jönköping County, Sweden.
¹⁰ Department of Surgery and Urology, Eskilstuna Hospital, Eskilstuna, Sweden.
¹¹ Department of Surgery, Malmö University Hospital, Lund University, Malmö, Sweden.
¹² Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden; Unit of Cardiovascular and Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
¹³ Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Södersjukhuset, Stockholm, Sweden.
¹⁴ Department of Surgical and Peri-operative Sciences, Umeå University, Umeå, Sweden.
¹⁵ Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Surgery, Västerås Central Hospital, Västerås, Sweden.
¹⁶ Department of Cardiothoracic and Vascular Surgery and Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
¹⁷ Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Surgical and Peri-operative Sciences, Umeå University, Umeå, Sweden.

PMID: 37356704
DOI: 10.1016/j.ejvs.2023.06.019

Abstract

Objective: Abdominal aortic graft and endograft infections (AGIs) are rare complications following aortic surgery. Radical surgery (RS) with resection of the infected graft and reconstruction with extra-anatomical bypass or in situ reconstruction is the preferred therapy. For patients unfit for RS, a semi-conservative (SC), graft preserving strategy is possible. This paper aimed to compare survival and infection outcomes between RS and SC treatment for AGI in a nationwide cohort.

Methods: Patients with abdominal AGI related surgery in Sweden between January 1995 and May 2017 were identified. The Management of Aortic Graft Infection Collaboration (MAGIC) criteria were used for the definition of AGI. Multivariable regression was performed to identify factors associated with mortality.

Results: One hundred and sixty-nine patients with surgically treated abdominal AGI were identified, comprising 43 SC (14 endografts; 53% with a graft enteric fistula [GEF] in total) and 126 RS (26 endografts; 50% with a GEF in total). The SC cohort was older and had a higher frequency of cardiac comorbidities. There was a non-significant trend towards lower Kaplan-Meier estimated five year survival for SC vs. RS (30.2% vs. 48.4%; p = .066). A non-significant trend was identified towards worse Kaplan-Meier estimated five year survival for SC patients with a GEF vs. without a GEF (21.7% vs. 40.1%; p = .097). There were significantly more recurrent graft infections comparing SC with RS (45.4% vs. 19.3%; p < .001). In a Cox regression model adjusting for confounders, there was no difference in five year survival comparing SC vs. RS (HR 1.0, 95% CI 0.6 - 1.5).

Conclusion: In this national AGI cohort, there was no mortality difference comparing SC and RS for AGI when adjusting for comorbidities. Presence of GEF probably negatively impacts survival outcomes of SC patients. Rates of recurrent infection remain high for SC treated patients.

Keywords: Aortic graft infection; Multicentre; Nationwide; Radical surgery; Semi-conservative.

MeSH terms

Aortic Aneurysm, Abdominal* / complications
Aortic Aneurysm, Abdominal* / diagnostic imaging
Aortic Aneurysm, Abdominal* / surgery
Blood Vessel Prosthesis / adverse effects
Blood Vessel Prosthesis Implantation* / adverse effects
Conservative Treatment / adverse effects
Endovascular Procedures* / adverse effects
Humans
Postoperative Complications / etiology
Prosthesis-Related Infections* / etiology
Prosthesis-Related Infections* / surgery
Retrospective Studies
Risk Factors
Treatment Outcome