1. Managing EVAR Graft Complications
Michael J. Reardon, M.D.
Professor of Cardiothoracic Surgery
Methodist DeBakey Heart & Vascular Center

2. Conflict of Interest Consultant to Medtronic CoreValve Trial
Steering committee member
SurTAVI Trial
National PI

3. Signs and Symptoms Low grade pyrexia Sepsis Weight loss Anorexia
Fatigue
Sepsis
Fever
Rigors
Shock

4. Presentation Imaging signs of graft infection Increase in sac diameter
Air in sac
Loss of tissue planes
Increase in sac diameter
Abscess formation
Destruction of spinal vertebral bodies
Anaemia
Occult gastrointestinal bleeding

5. Presentation Rupture Fistula Aortoenteric Aorto-oesophageal
Aortobronchial
Aortocutaneous

7. Culture
Blood cultures x3 before antimicrobials given Culture fluid, bone, thrombus, device if removed Pre-operative antibiotic course improves outcome If rupture no opportunity

8. Antimicrobials Positive culture: sensitivities to drugs
Negative culture: broad spectrum
When to stop?
When indices return to normal:
White blood cells, erythrocyte sedimentation rate, c-reactive protein
For ever
When patient refuses to take any more
PICC lines, portacath with central line

9. Organisms Culture negative 25% Staphylococcus aureus 30%
Salmonella %
Streptococcus 10%
Staphylococcus albus
Escherichia Coli

10. CT guided aspiration -
propionibacterium acnes

11. Other Reported Organisms
Proteus
Serratia
Enterobacter
Neisseria
Mycobacterium
Propionibacterium
Clostridium
Enterococcus
Bacteriodes
Candida
Klebsiella
Actinobacter

12. Treatment Options Intravenous antimicrobials Drainage and irrigation
Better outcome if further from procedure
Drainage and irrigation
Further endovascular repair
Useful to control haemorrhage
Inevitably will become infected
Bridge to definitive repair
Timing of definitive repair very important

13. Treatment Options Removal of the device and extensive debridement
In situ reconstruction:
antibiotic soaked grafts, silver impregnated grafts, autologous grafts, homografts
Extra-anatomic reconstruction
Omentum to cover aorta and sac
Drainage

14. Large abdominal germ cell tumor
25 year old male
Large abdominal germ cell tumor
Duodenal aorto fistula with 25 unit bleed
Endograft abdominal aorta – stops bleed
Chemotherapy – no evidence of disease
Intermittent fever and chills

17. Allograft

18. 47 year old female had bleeding into her left chest after a previous spinal fusion with instrumentation
Receives a thoracic endograft that controls bleeding

19. 5 months after endograft she develops fever and hemoptysis
Evidence of contrast outside of endograft on CT scan
Open repair

20. Infected Endografts 62 cases
49 (79%) removed with either in-situ or extra-anatomic reconstruction
Mortality rate 16%
11 (18%) were treated with antibiotics with or without drainage
Mortality rate 36% at 3 months
Fiorani P et al J Endovasc Ther 2003; 10:

21. Belfast 409 patients EVAR AAA 6 (1.5%) infected 2 psoas abscess:
graft removed with extra-anatomic bypass OK
2 infected grafts:
one removed with extra-anatomic bypass OK
one treated conservatively died
1 died suddenly:
Post Mortem aortoenteric fistula
1 died untreated as inoperable cancer
Sharif MA et al J Vasc Surg 2007; 46: 442-8

22. Chicago 2000-7 Infections Mean time from implantation 243 days
5/389 EVAR (0.26%) 5/106 TEVAR (4.77%)
Mean time from implantation 243 days
2 had contained rupture
Rest infections and/or abscess on imaging
Propionibacterium 3, Staph 3, Strep 2, Enterobacter 1

23. Chicago
All EVAR removed with extra-anatomic bypass in 3 and in situ in 2
TEVAR 1 removal
4 treated medically with 1 survivor, 2 died of rupture and of MSOF from sepsis
Heyer et al J Vasc Interv Radio 2009; 20: 173-9

24. University of Michigan
9 patients
Mean time 33 months post implant
Investigations: CT, MR, white cell scan
Rifampicin soaked in situ grafts 4
Extra-anatomic bypass 5
E coli, Bacteroides, Staph, Strep, Candida
1 died of aortoenteric fistula
3 others developed an aortoenteric fistula 2 died
Laser A et al J Vasc Surg 2011; Feb Epub

25. Guy’s & St Thomas’ 10 infected aortic grafts:
3 TEVAR drainage and long term antibiotics
All alive and well; portacath, PICC line, oral
7 EVAR all removed with axillobifemoral grafts
2 deaths: iliac haemorrhage, respiratory failure
5 alive and well
1 concurrent spinal reconstruction
1 spinal brace

26. World Literature 2010 EVAR for AAA 102 reported infections since 1991
Options:
Antibiotics and percutaneous drainage
Explantation and in situ or extra-anatomic bypass
Outcome best for explantation and in situ replacement
Setacci C et al J Cardiovasc Surg (Torino) 2010; 51: 33-41

27. Summary Infected endografts likely to be an increasing problem
Culture and antibiotic therapy
Drainage
Removal
in-situ autologous reconstruction
Silver impregnated, antibiotic soaked grafts
Extra-anatomic reconstruction

28. Summary Antibiotic therapy Long term intravenous PICC, portacath
Long term oral; reduced dose
Stop when no evidence of infection
Pragmatically when patient stops taking them

29. Thank You