Conservative Management First Strategy in Aortic Vascular Graft and Endograft Infections.

OBJECTIVE: The aim of this study was to describe and present the outcomes of a specific treatment protocol for aortic vascular graft and endograft infections (VGEIs) without explantation of the infected graft.

METHODS: This was a retrospective, observational single centre cohort study carried out between 2012 and 2022 at a tertiary hospital. An aortic VGEI was defined according to the Management of Aortic Graft Infection Collaboration (MAGIC) criteria. Fitness for graft excision was assessed by a multidisciplinary team and included an evaluation of the patient's general condition, septic status, and anatomical complexity. Antimicrobial treatments were individualised. The primary outcome was survival at the last available follow up; secondary outcomes were antimicrobial treatment duration, infection eradication, treatment failure despite antimicrobial treatment, and the development of aortic fistulation.

RESULTS: Fifty patients were included in the study, of whom 42 (84%) had had previous endovascular repair. The median patient age was 72 years (range 51 - 82 years) and median duration of treatment with antimicrobials was 18 months (range 1 - 164 months). Kaplan-Meier analysis estimated the 30 day survival to be 98% (95% confidence interval [CI] 96 - 100), the one year survival rate to be 88% (95% CI 83.4 - 92.6), and the three year survival rate to be 79% (95% CI 72.7 - 84.7). Twenty-four (48%) patients were able to discontinue antibiotic treatment after a median of 16 months (range 4 - 81 months). When categorised according to infected graft location, deaths occurred in four (40%) patients with thoracic, two (40%) with paravisceral, seven (30%) with infrarenal VGEIs, and in one (25%) patient with an aorto-iliac VGEI; no (0%) patient with a thoraco-abdominal VGEI died.

CONCLUSION: Identifying the microbiological aetiology in patients with aortic VGEI enables individualised, specific antibiotic treatment, which may be useful in patients with a VGEI excluded from surgery. This single centre retrospective analysis of patients with VGEIs without fistula selected for conservative treatment suggests that conservative management of aortic VGEIs with targeted antibiotic therapy without graft excision is potentially effective, and that antimicrobial treatment will not necessarily be needed indefinitely.