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Aortic infections: The Nadir of Vascular Surgery
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Aortic infections are rare, life-threatening and constitute a major challenge in surgical management. This thesis aims to evaluate short – and long-term outcome of endovascular aortic repair (EVAR) for mycotic aortic aneurysms (MAA) and the subsequent risk of recurrent infections, changes in surgical practice over time for abdominal MAAs in Sweden and outcome for different treatment modalities, as well as the risk of secondary vascular infection after treatment with Open abdomen after aortic surgery.

Paper I, a retrospective single centre study of patients with MAA treated with EVAR, demonstrated a good short-term outcome, 91% survival at 30-days, and acceptable mid-term survival, 73% at 1-year.

Paper II, a retrospective international multicentre study of patients treated with EVAR for MAA, confirmed the results in paper I, and showed that EVAR is feasible and for most MAA patients a durable treatment option, 5-year survival was 55% and 10-year 41%. A total of 19% died from an infection-related complication, mostly during the first postoperative year. Non-Salmonella-positive culture was a predictor for late infection–related death.

Paper III, a population-based cohort study on all abdominal MAAs operated on between 1994-2014 in Sweden. Overall survival was 86% at 3-months, 79% at 1-year and 59% at 5-years. The survival was significantly better after endovascular compared to open repair up to 1-year without increasing recurrence of infection or reoperation, thereafter there was no difference. After 2001 EVAR constituted 60 % of all repairs, thus indicating a paradigm shift in treatment for abdominal MAAs in Sweden.

Paper IV, a prospective multicentre study of patients treated with open abdomen after aortic surgery. Infectious complications, such as graft infections, occurred after intestinal ischaemia and prolonged OA-treatment, and were often fatal.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2016. , 77 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1249
Keyword [en]
Mycotic, aortic, aneurysm, surgery, infection, endovascular repair, open abdomen
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-300954ISBN: 978-91-554-9663-0 (print)OAI: oai:DiVA.org:uu-300954DiVA: diva2:953002
Public defence
2016-10-22, Auditorium minus, Gustavianum, Akademigatan 3, Uppsala, 13:15 (English)
Opponent
Supervisors
Available from: 2016-09-23 Created: 2016-08-16 Last updated: 2016-10-11
List of papers
1. Endovascular repair of mycotic aortic aneurysms
Open this publication in new window or tab >>Endovascular repair of mycotic aortic aneurysms
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2009 (English)In: Journal of vascular surgery, ISSN 0741-5214, Vol. 50, no 2, 269-274 p.Article in journal (Refereed) Published
Abstract [en]

PURPOSE: We report our single-center experience of early and midterm outcome after endovascular repair of mycotic aortic aneurysms (MAA). METHODS: Case records were retrospectively reviewed of 11 patients who underwent endovascular repair of 13 MAAs between 2000 and 2007. The aneurysms were localized in the aortic arch in 1 patient, descending thoracic aorta in 4, suprarenal abdominal aorta in 3, and infrarenal abdominal aorta in 5. RESULTS: Mean follow-up was 27 months. A bleeding aortoesophageal fistula resulted in one in-hospital death <or=30 days. Three patients died later: one each of sepsis, stent migration that caused intestinal ischemia, and an unknown cause. Two patients had recurrent sepsis postoperatively but no vascular complications, two had elevated inflammatory markers during follow-up but were asymptomatic, and three patients had an uneventful follow-up. CONCLUSIONS: Endovascular treatment for MAA was feasible, with acceptable perioperative mortality and midterm outcome in this single-center case series. Recurrent sepsis and late relapse with a second MAA occurred, indicating the need of long-term antibiotic therapy and follow-up, as well as the possible need for secondary open repair in selected cases. Further research is warranted to evaluate long-term outcome.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-110122 (URN)10.1016/j.jvs.2009.01.001 (DOI)000268610000005 ()19446985 (PubMedID)
Available from: 2009-11-04 Created: 2009-11-04 Last updated: 2016-08-31Bibliographically approved
2. Endovascular Treatment of Mycotic Aortic Aneurysms A European Multicenter Study
Open this publication in new window or tab >>Endovascular Treatment of Mycotic Aortic Aneurysms A European Multicenter Study
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2014 (English)In: Circulation, ISSN 0009-7322, E-ISSN 1524-4539, Vol. 130, no 24, 2136-2142 p.Article in journal (Refereed) Published
Abstract [en]

Background-Mycotic aortic aneurysm (MAA) is a rare and life-threatening disease. The aim of this European multicenter collaboration was to study the durability of endovascular aortic repair (EVAR) of MAA, by assessing late infection-related complications and long-term survival. Methods and Results-All EVAR treated MAAs, between 1999 and 2013 at 16 European centers, were retrospectively reviewed. One hundred twenty-three patients with 130 MAAs were identified. Mean age was 69 years (range 39-86), 87 (71%) were men, 58 (47%) had immunodeficiency, and 47 (38%) presented with rupture. Anatomic locations were ascending/arch (n=4), descending (n=34), paravisceral (n=15), infrarenal aorta (n=63), and multiple (n=7). Treatments were thoracic EVAR (n=43), fenestrated/branched EVAR (n=9), and infrarenal EVAR (n=71). Antibiotic was administered for mean 30 weeks. Mean follow-up was 35 months (range 1 week to 149 months). Six patients (5%) were converted to open repair during follow-up. Survival was 91% (95% confidence interval, 86% to 96%), 75% (67% to 83%), 55% (44% to 66%), and 41% (28% to 54%) after 1, 12, 60, and 120 months, respectively. Infection-related death occurred in 23 patients (19%), 9 after discontinuation of antibiotic treatment. A Cox regression analysis demonstrated non-Salmonella-positive culture as predictors for late infection-related death. Conclusions-Endovascular treatment of MAA is feasible and for most patients a durable treatment option. Late infections do occur, are often lethal, and warrant long-term antibiotic treatment and follow-up. Patients with non-Salmonellapositive blood cultures were more likely to die from late infection.

Keyword
aneurysm, aorta, infection, surgery
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-241408 (URN)10.1161/CIRCULATIONAHA.114.009481 (DOI)000346141900011 ()25378548 (PubMedID)
Available from: 2015-01-19 Created: 2015-01-12 Last updated: 2017-12-05Bibliographically approved
3. Nationwide study demonstrates paradigm shift in treatment of mycotic abdominal aortic aneurysms
Open this publication in new window or tab >>Nationwide study demonstrates paradigm shift in treatment of mycotic abdominal aortic aneurysms
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Radical open surgery (OR) is considered gold standard for management of mycotic abdominal aortic aneurysms (MAAAs). Endovascular repair (EVAR) is a less invasive but controversial treatment option for MAAA because the stentgraft is implanted in an infected field, whilst recent reports indicate promising outcome. No reliable comparative data exists. This nationwide study assesses outcome after OR and EVAR for MAAA in a population-based cohort.

Methods: All patients treated in Sweden for MAAAs 1994-2014 were identified in the Swedish vascular registry. Twenty-seven vascular units participated in data collection according to a predefined protocol. Survival was cross-matched with the population registry.

Results: 132 patients with 144 MAAAs were identified, (0.6% of all operated AAA in Sweden). Median age was 70 years (SD 9.2), 51 were immunosuppressed, and 50 presented with rupture. Survival at 3-months was 86% (95% CI 80-92%), 1-year 79% (72-86%), and 5- years 59% (50-68%).

The preferred operative technique shifted from OR to EVAR after 2001 (proportion EVAR 1994-2000 0%, 2001-2007 58%, 2008-2014 60%). Open repair was performed in 62 patients (47%); aortic resection and extra-anatomical bypass (n=7), in-situ reconstruction (n=50), patch plasty (n=3), and two died intraoperatively OR attempt. EVAR was performed in 70 patients (53%); standard EVAR (n=55), fenestrated/branched EVAR (n=8), and visceral deviation with stentgrafting (n=7).

Survival at 3-months was inferior for OR compared to EVAR in Kaplan-Meier analysis (74% vs 96%, p<0.001), with a similar trend present at 1-year (73% vs 84%, p=0.054). A propensity score weighted risk-adjusted analysis confirmed the early survival benefit of EVAR. During follow-up (median OR 36, EVAR 41 months) there was no difference in long- term survival (5-years 60 vs 58%, p=0.771), infection-related complications (18 vs 24%, p=0.439), or reoperation (21% vs 24%, p=0.650). In a multivariable analysis OR was a significant risk factor for death at 3-months (odds ratio 6.96, p=0.004).

Conclusion: This study demonstrates a paradigm shift in treatment of MAAA in Sweden, with EVAR being the preferred treatment modality. EVAR achieved improved short-term survival compared to OR, without increasing the risk of serious infection-related complications or reoperations.

Keyword
Mycotic, infected, aortic, aneurysm, abdominal
National Category
Medical and Health Sciences
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-300952 (URN)
Available from: 2016-08-16 Created: 2016-08-16 Last updated: 2016-08-31Bibliographically approved
4. Open Abdomen Treatment after Aortic Aneurysm Repair with Vacuum-assisted Wound Closure and Mesh-mediated Fascial Traction
Open this publication in new window or tab >>Open Abdomen Treatment after Aortic Aneurysm Repair with Vacuum-assisted Wound Closure and Mesh-mediated Fascial Traction
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2013 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 45, no 6, 588-594 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES:

Open abdomen (OA) treatment is sometimes necessary after surgery for aortic aneurysm (AA), to prevent or treat abdominal compartment syndrome (ACS). A multicentre study evaluating vacuum-assisted wound closure (100-150 mmHg) and mesh-mediated fascial traction (VAWCM) was performed.

METHODS:

All patients treated with OA after AA repair (2006-2009) were prospectively registered at four centres; those treated <5 days were excluded. All surviving patients underwent a 1-year follow-up, including computed tomography (CT) examination.

RESULTS:

Among 1041 patients treated with open or endovascular repair of AA, 28 (2.9%) had OA treatment with VAWCM; another two had VAWCM after hybrid operations for thoraco-abdominal AA. Eighteen (60%) were operated on for rupture and 12 (40%) electively. Eight had suprarenal or thoraco-abdominal aneurysms. Eight (27%) died within 30 days, none due to OA-related complications. Four died before abdominal closure; primary delayed fascial closure was achieved in all survivors. One-year mortality was 50%. Ten (33%) had bowel ischaemia requiring bowel resection. Late potential OA-related infectious complications occurred in five (17%), all of whom first developed intestinal ischaemia: entero-atmospheric fistulae (two), graft infections (two), aorto-enteric fistula (one). One year follow-up with clinical evaluation and CT showed no signs of graft infection. Incisional hernias occurred in 9 of 15 patients (60%); only three were symptomatic.

CONCLUSION:

VAWCM provided high fascial closure rate after AA repair and long-term OA treatment. Infectious complications occur after intestinal ischaemia and prolonged OA treatment, and are often fatal. The poor prognosis among patients needing OA after AA surgery may be improved by using VAWCM, permitting earlier closure.

Keyword
Aortic aneurysm; Open abdomen; Vacuum-assisted wound closure; Mesh; Abdominal compartment syndrome; Mortality; Infections
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-199892 (URN)10.1016/j.ejvs.2013.01.041 (DOI)000320745100010 ()23465456 (PubMedID)
Funder
Swedish Research Council, K2010-65X-20406-04-3
Available from: 2013-05-17 Created: 2013-05-17 Last updated: 2017-12-06Bibliographically approved

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