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

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

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

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

Presentation Rupture Fistula Aortoenteric Aorto-oesophageal Aortobronchial Aortocutaneous

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

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

Organisms Culture negative 25% Staphylococcus aureus 30% Salmonella 15% Streptococcus 10% Staphylococcus albus Escherichia Coli

CT guided aspiration - propionibacterium acnes

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

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

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

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

Allograft

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

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

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; 10:919-927

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

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

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

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

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

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

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

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

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