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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.

Background: Aortic endograft infection (AeGI) is a rare but severe complication following complex endovascular aortic repair (cEVAR). Data on its true incidence, risk factors, clinical course, and outcomes is limited to very small case series. This study aimed to determine the incidence and risk factors for AeGI after cEVAR and to describe treatment strategies and outcomes in a complex aortic high-volume center.

Methods: All patients undergoing cEVAR with fenestrated or branched endografts at Uppsala University Hospital, Sweden, between September 2010 and May 2024 were retrospectively identified. Data were crosschecked with the Swedish vascular registry (Swedvasc). AeGI was defined according to the Management of Aortic Graft Infection Collaboration (MAGIC) criteria. Risk factors were assessed using multivariable Cox regression. Outcomes including incidence, microbiology, treatment strategies, survival, and long-term infection status were assessed.

Results: Among 527 patients (542 cEVARs, median follow-up 47.4 months), 19 (3.6%; 723/100 000 patient-years) developed MAGIC-diagnosed AeGI. Independent risk factors to develop complex AeGI was infected native aortic aneurysm (INAA) as index pathology (HR 10.2, CI95: 3.13–33.2) and late aortic-related reinterventions (HR 2.98, CI95: 1.1–7.9). Median time from primary cEVAR to AeGI diagnosis was 10.6 months (IQR: 6.12-31.0 months). Six patients (32%) had a secondary fistula/erosion, associated with poor median survival (fistula: 4.0 months vs. no fistula: 41.5 months). Treatment strategies were almost exclusively graft-persevering; antimicrobial therapy alone 11/19 (58%) or combined with image-guided drainage and/or surgical debridement 7/19 (37%). At last follow-up, remission was achieved in 50%, and treatment failure in 44%, mainly due to AeGI-related mortality.

Conclusion: AeGI after cEVAR is more common than previously reported. Risk is further increased by INAA as index pathology and late aortic reinterventions. Prognosis is poor in patients with secondary fistula, while conservative graft-preserving strategies may achieve durable infectious remission and survival in selected patients.