Infected Aortic Grafts in the Descending Thoracic Aorta

  • Rana O. Afifi
  • Kristofer M. Charlton-Ouw
  • Hazim J. Safi
  • Anthony L. EstreraEmail author


Prosthetic graft or endograft infection is a rare but devastating complication of aortic surgery. The incidence of infected descending and thoracoabdominal prosthetic grafts is reported between 0.5 and 1.7%, including early and late infections with and without aortoesophageal fistulas. The prevalence of infected aortic endografts is 0.25–4%. Improvements in surgical techniques, endovascular therapies as bridging procedures and perioperative care have led to improved in-hospital survival. Replacement of the infected graft with pedicled flap coverage leads to reasonable long-term results. Additional studies are needed before widespread adoption of graft preservation techniques.


Graft infection Positron-emission tomography Homograft Neuromonitoring Antibiotic-loaded beads 


  1. 1.
    Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg. 1993;17:357–68.PubMedCrossRefGoogle Scholar
  2. 2.
    Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Variables predictive of outcome in 832 patients undergoing repairs of the descending thoracic aorta. Chest. 1993;104:1248–53.PubMedCrossRefGoogle Scholar
  3. 3.
    Herdrich BJ, Fairman RM. How to manage infected aortic endografts. J Cardiovasc Surg. 2013;54:595–604.Google Scholar
  4. 4.
    Ducasse E, Calisti A, Speziale F, Rizzo L, Misuraca M, Fiorani P. Aortoiliac stent graft infection: current problems and management. Ann Vasc Surg. 2004;18:521–6.PubMedCrossRefGoogle Scholar
  5. 5.
    Heyer KS, Modi P, Morasch MD, et al. Secondary infections of thoracic and abdominal aortic endografts. J Vasc Interv Radiol. 2009;20:173–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Bandyk DF, Berni GA, Thiele BL, Towne JB. Aortofemoral graft infection due to Staphylococcus epidermidis. Arch Surg. 1984;119:102–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Lorentzen JE, Nielsen OM, Arendrup H, et al. Vascular graft infection: an analysis of sixty-two graft infections in 2411 consecutively implanted synthetic vascular grafts. Surgery. 1985;98:81–6.PubMedGoogle Scholar
  8. 8.
    Kan CD, Lee HL, Yang YJ. Outcome after endovascular stent graft treatment for mycotic aortic aneurysm: a systematic review. J Vasc Surg. 2007;46:906–12.PubMedCrossRefGoogle Scholar
  9. 9.
    Kakkos SK, Antoniadis PN, Klonaris CN, et al. Open or endovascular repair of aortoenteric fistulas? A multicentre comparative study. Eur J Vasc Endovasc Surg. 2011;41:625–34.PubMedCrossRefGoogle Scholar
  10. 10.
    Swain TW 3rd, Calligaro KD, Dougherty MD. Management of infected aortic prosthetic grafts. Vasc Endovasc Surg. 2004;38:75–82.CrossRefGoogle Scholar
  11. 11.
    Orton DF, LeVeen RF, Saigh JA, et al. Aortic prosthetic graft infections: radiologic manifestations and implications for management. Radiographics. 2000;20:977–93.PubMedCrossRefGoogle Scholar
  12. 12.
    Legout L, D’Elia PV, Sarraz-Bournet B, et al. Diagnosis and management of prosthetic vascular graft infections. Med Mal Infect. 2012;42:102–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Low RN, Wall SD, Jeffrey RB Jr, Sollitto RA, Reilly LM, Tierney LM Jr. Aortoenteric fistula and perigraft infection: evaluation with CT. Radiology. 1990;175:157–62.PubMedCrossRefGoogle Scholar
  14. 14.
    Fiorani P, Speziale F, Rizzo L, et al. Detection of aortic graft infection with leukocytes labeled with technetium 99m-hexametazime. J Vasc Surg. 1993;17:87–95.PubMedCrossRefGoogle Scholar
  15. 15.
    McKeown PP, Miller DC, Jamieson SW, et al. Diagnosis of arterial prosthetic graft infection by indium-111 oxine white blood cell scans. Circulation. 1982;66:I130–4.PubMedGoogle Scholar
  16. 16.
    Love C, Palestro CJ. Radionuclide imaging of infection. J Nucl Med Technol. 2004;32:47–57.PubMedGoogle Scholar
  17. 17.
    Fukuchi K, Ishida Y, Higashi M, et al. Detection of aortic graft infection by fluorodeoxyglucose positron emission tomography: comparison with computed tomographic findings. J Vasc Surg. 2005;42:919–25.PubMedCrossRefGoogle Scholar
  18. 18.
    Keidar Z, Engel A, Hoffman A, Israel O, Nitecki S. Prosthetic vascular graft infection: the role of 18F-FDG PET/CT. J Nucl Med. 2007;48:1230–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Tokuda Y, Oshima H, Araki Y, et al. Detection of thoracic aortic prosthetic graft infection with 18F-fluorodeoxyglucose positron emission tomography/computed tomography. Eur J Cardiothorac Surg. 2013;43:1183–7.PubMedCrossRefGoogle Scholar
  20. 20.
    Wasselius J, Malmstedt J, Kalin B, et al. High 18F-FDG uptake in synthetic aortic vascular grafts on PET/CT in symptomatic and asymptomatic patients. J Nucl Med. 2008;49:1601–5.PubMedCrossRefGoogle Scholar
  21. 21.
    Keidar Z, Nitecki S. FDG-PET for the detection of infected vascular grafts. Q J Nucl Med Mol Imaging. 2009;53:35–40.PubMedGoogle Scholar
  22. 22.
    Calligaro KD, Veith FJ. Diagnosis and management of infected prosthetic aortic grafts. Surgery. 1991;110:805–13.PubMedGoogle Scholar
  23. 23.
    Hsu RB, Lin FY. Infected aneurysm of the thoracic aorta. J Vasc Surg. 2008;47:270–6.PubMedCrossRefGoogle Scholar
  24. 24.
    Weis-Muller BT, Rascanu C, Sagban A, Grabitz K, Godehardt E, Sandmann W. Single-center experience with open surgical treatment of 36 infected aneurysms of the thoracic, thoracoabdominal, and abdominal aorta. Ann Vasc Surg. 2011;25:1020–5.PubMedCrossRefGoogle Scholar
  25. 25.
    Chan FY, Crawford ES, Coselli JS, Safi HJ, Williams TW Jr. In situ prosthetic graft replacement for mycotic aneurysm of the aorta. Ann Thorac Surg. 1989;47:193–203.PubMedCrossRefGoogle Scholar
  26. 26.
    Crawford ES, Reardon MJ, Williams TW Jr. Surgical considerations of infection following operations involving the descending thoracic aorta. World J Surg. 1980;4:669–77.PubMedCrossRefGoogle Scholar
  27. 27.
    Hargrove WC 3rd, Edmunds LH Jr. Management of infected thoracic aortic prosthetic grafts. Ann Thorac Surg. 1984;37:72–7.PubMedCrossRefGoogle Scholar
  28. 28.
    Barnard SP, Dark JH, Jones NA. Prosthetic graft infection in the descending thoracic aorta treated by extra-anatomic rerouting. Cardiovasc Surg. 1995;3:703–5.PubMedCrossRefGoogle Scholar
  29. 29.
    Watts SH. VIII. The suture of blood vessels. Implantation and transplantation of vessels and organs. An historical and experimental study. Ann Surg. 1907;46:373–404.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    Carrel A. Landmark article, Nov 14, 1908: results of the transplantation of blood vessels, organs and limbs. By Alexis Carrel. JAMA. 1983;250:944–53.PubMedCrossRefGoogle Scholar
  31. 31.
    Dubost C, Allary M, Oeconomos N. Resection of an aneurysm of the abdominal aorta: reestablishment of the continuity by a preserved human arterial graft, with result after five months. AMA Arch Surg. 1952;64:405–8.PubMedCrossRefGoogle Scholar
  32. 32.
    Nuboer JF. Treatment of certain coarctations with homologous grafts, fixed in 4% formalin. Arch Chir Neerl. 1954;6:123–42.PubMedGoogle Scholar
  33. 33.
    Kieffer E, Gomes D, Chiche L, Fleron MH, Koskas F, Bahnini A. Allograft replacement for infrarenal aortic graft infection: early and late results in 179 patients. J Vasc Surg. 2004;39:1009–17.PubMedCrossRefGoogle Scholar
  34. 34.
    Vogt PR, von Segesser LK, Goffin Y, et al. Eradication of aortic infections with the use of cryopreserved arterial homografts. Ann Thorac Surg. 1996;62:640–5.PubMedCrossRefGoogle Scholar
  35. 35.
    Vogt PR, Pfammatter T, Schlumpf R, et al. In situ repair of aortobronchial, aortoesophageal, and aortoenteric fistulae with cryopreserved aortic homografts. J Vasc Surg. 1997;26:11–7.PubMedCrossRefGoogle Scholar
  36. 36.
    Vogt PR, Brunner-La Rocca HP, Carrel T, et al. Cryopreserved arterial allografts in the treatment of major vascular infection: a comparison with conventional surgical techniques. J Thorac Cardiovasc Surg. 1998;116:965–72.PubMedCrossRefGoogle Scholar
  37. 37.
    Vogt PR, Turina MI. Management of infected aortic grafts: development of less invasive surgery using cryopreserved homografts. Ann Thorac Surg. 1999;67:1986–9.PubMedCrossRefGoogle Scholar
  38. 38.
    Vogt PR. Arterial allografts in treating aortic graft infections: something old, something new. Semin Vasc Surg. 2011;24:227–33.PubMedCrossRefGoogle Scholar
  39. 39.
    Vogt PR, Brunner-LaRocca HP, Lachat M, Ruef C, Turina MI. Technical details with the use of cryopreserved arterial allografts for aortic infection: influence on early and midterm mortality. J Vasc Surg. 2002;35:80–6.PubMedCrossRefGoogle Scholar
  40. 40.
    von Segesser LK, Tkebuchava T, Niederhauser U, et al. Aortobronchial and aortoesophageal fistulae as risk factors in surgery of descending thoracic aortic aneurysms. Eur J Cardiothorac Surg. 1997;12:195–201.CrossRefGoogle Scholar
  41. 41.
    Kieffer E, Sabatier J, Plissonnier D, Knosalla C. Prosthetic graft infection after descending thoracic/ thoracoabdominal aortic aneurysmectomy: management with in situ arterial allografts. J Vasc Surg. 2001;33:671–8.PubMedCrossRefGoogle Scholar
  42. 42.
    Noel AA, Gloviczki P, Cherry KJ Jr, et al. Abdominal aortic reconstruction in infected fields: early results of the United States cryopreserved aortic allograft registry. J Vasc Surg. 2002;35:847–52.PubMedCrossRefGoogle Scholar
  43. 43.
    Clagett GP, Bowers BL, Lopez-Viego MA, et al. Creation of a neo-aortoiliac system from lower extremity deep and superficial veins. Ann Surg. 1993;218:239–48.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Nevelsteen A, Lacroix H, Suy R. Autogenous reconstruction with the lower extremity deep veins: an alternative treatment of prosthetic infection after reconstructive surgery for aortoiliac disease. J Vasc Surg. 1995;22:129–34.PubMedCrossRefGoogle Scholar
  45. 45.
    Ali AT, Modrall JG, Hocking J, et al. Long-term results of the treatment of aortic graft infection by in situ replacement with femoral popliteal vein grafts. J Vasc Surg. 2009;50:30–9.PubMedCrossRefGoogle Scholar
  46. 46.
    Chung J, Clagett GP. Neoaortoiliac System (NAIS) procedure for the treatment of the infected aortic graft. Semin Vasc Surg. 2011;24:220–6.PubMedCrossRefGoogle Scholar
  47. 47.
    Gibbons CP, Ferguson CJ, Fligelstone LJ, Edwards K. Experience with femoro-popliteal vein as a conduit for vascular reconstruction in infected fields. Eur J Vasc Endovasc Surg. 2003;25:424–31.PubMedCrossRefGoogle Scholar
  48. 48.
    Okamoto H, Tamenishi A, Matsumura Y, Niimi T. Composite vein graft reconstruction for infected descending aortic prosthesis. Ann Thorac Surg. 2012;93:2061–3.PubMedCrossRefGoogle Scholar
  49. 49.
    Weinberg CB, Bell E. A blood vessel model constructed from collagen and cultured vascular cells. Science. 1986;231:397–400.PubMedCrossRefGoogle Scholar
  50. 50.
    Naito Y, Rocco K, Kurobe H, Maxfield M, Breuer C, Shinoka T. Tissue engineering in the vasculature. Anat Rec. 2014;297:83–97.CrossRefGoogle Scholar
  51. 51.
    Shin’oka T, Imai Y, Ikada Y. Transplantation of a tissue-engineered pulmonary artery. N Engl J Med. 2001;344:532–3.PubMedCrossRefGoogle Scholar
  52. 52.
    Shin’oka T, Matsumura G, Hibino N, et al. Midterm clinical result of tissue-engineered vascular autografts seeded with autologous bone marrow cells. J Thorac Cardiovasc Surg. 2005;129:1330–8.PubMedCrossRefGoogle Scholar
  53. 53.
    Hibino N, McGillicuddy E, Matsumura G, et al. Late-term results of tissue-engineered vascular grafts in humans. J Thorac Cardiovasc Surg. 2010;139:431–6.PubMedCrossRefGoogle Scholar
  54. 54.
    DuBose JJ, Azizzadeh A. Utilization of a tubularized CorMatrix extracellular matrix for repair of an arteriovenous fistula aneurysm. Ann Vasc Surg. 2015;29:366.PubMedCrossRefGoogle Scholar
  55. 55.
    Rosario-Quinones F, Magid MS, Yau J, Pawale A, Nguyen K. Tissue reaction to porcine intestinal submucosa (CorMatrix) implants in pediatric cardiac patients: a single-center experience. Ann Thorac Surg. 2015;99:1373–7.PubMedCrossRefGoogle Scholar
  56. 56.
    Deorsola L, Pace Napoleone C, Abbruzzese PA. Repair of an unusual aortic coarctation using an extracellular matrix patch. Ann Thorac Surg. 2014;97:1059–61.PubMedCrossRefGoogle Scholar
  57. 57.
    Fallon A, Goodchild T, Wang R, Matheny RG. Remodeling of extracellular matrix patch used for carotid artery repair. J Surg Res. 2012;175:25–34.CrossRefGoogle Scholar
  58. 58.
    Sundermann SH, Rodriguez Cetina Biefer H, Emmert MY, Falk V. Use of extracellular matrix materials in patients with endocarditis. Thorac Cardiovasc Surg. 2014;62:76–9.PubMedCrossRefGoogle Scholar
  59. 59.
    Piterina AV, Cloonan AJ, Meaney CL, et al. ECM-based materials in cardiovascular applications: inherent healing potential and augmentation of native regenerative processes. Int J Mol Sci. 2009;10:4375–417.PubMedPubMedCentralCrossRefGoogle Scholar
  60. 60.
    Coselli JS, Crawford ES, Williams TW, et al. Treatment of postoperative infection of ascending aorta and transverse aortic arch, including use of viable omentum and muscle flaps. Ann Thorac Surg. 1990;50:868–81.PubMedCrossRefGoogle Scholar
  61. 61.
    Quinones-Baldrich WJ, Nene SM, Gelabert HA, Moore WS. Rupture of the perivisceral aorta: atherosclerotic versus mycotic aneurysm. Ann Vasc Surg. 1997;11:331–41.PubMedCrossRefGoogle Scholar
  62. 62.
    Safi HJ. How I do it: thoracoabdominal aortic aneurysm graft replacement. Cardiovasc Surg. 1999;7:607–13.PubMedCrossRefGoogle Scholar
  63. 63.
    Miller CC 3rd, Villa MA, Sutton J, et al. Serum myoglobin and renal morbidity and mortality following thoracic and thoraco-abdominal aortic repair: does rhabdomyolysis play a role? Eur J Vasc Endovasc Surg. 2009;37:388–94.PubMedCrossRefGoogle Scholar
  64. 64.
    Avramovic J, Fletcher JP. Prevention of prosthetic vascular graft infection by rifampicin impregnation of a protein-sealed Dacron graft in combination with parenteral cephalosporin. J Cardiovasc Surg. 1992;33:70–4.Google Scholar
  65. 65.
    Goeau-Brissonniere O, Mercier F, Nicolas MH, et al. Treatment of vascular graft infection by in situ replacement with a rifampin-bonded gelatin-sealed Dacron graft. J Vasc Surg. 1994;19:739–41.PubMedCrossRefGoogle Scholar
  66. 66.
    Coggia M, Goeau-Brissonniere O, Leflon V, Nicolas MH, Pechere JC. Experimental treatment of vascular graft infection due to Staphylococcus epidermidis by in situ replacement with a rifampin-bonded polyester graft. Ann Vasc Surg. 2001;15:421–9.PubMedCrossRefGoogle Scholar
  67. 67.
    Seguin JR, Loisance DY. Omental transposition for closure of median sternotomy following severe mediastinal and vascular infection. Chest. 1985;88:684–6.PubMedCrossRefGoogle Scholar
  68. 68.
    Miller DW Jr, Johnson DD. Omental pedicle graft in the management of infected ascending aortic prostheses. Ann Thorac Surg. 1987;44:614–7.PubMedCrossRefGoogle Scholar
  69. 69.
    Nakajima N, Masuda M, Ichinose M, Ando M. A new method for the treatment of graft infection in the thoracic aorta: in situ preservation. Ann Thorac Surg. 1999;67:1994–6.PubMedCrossRefGoogle Scholar
  70. 70.
    Soyer R, Bessou JP, Bouchart F, Redonnet M, Mouton-Schleifer D, Arrignon J. Surgical treatment of infected composite graft after replacement of ascending aorta. Ann Thorac Surg. 1994;58:425–8.PubMedCrossRefGoogle Scholar
  71. 71.
    Cartier R, Brunette I, Hashimoto K, Bourne WM, Schaff HV. Angiogenic factor: a possible mechanism for neovascularization produced by omental pedicles. J Thoracic Cardiovasc Surg. 1990;99:264–8.Google Scholar
  72. 72.
    Lee AB Jr, Schimert G, Shaktin S, Seigel JH. Total excision of the sternum and thoracic pedicle transposition of the greater omentum; useful strategems in managing severe mediastinal infection following open heart surgery. Surgery. 1976;80:433–6.PubMedGoogle Scholar
  73. 73.
    Chachques JC, Grandjean PA, Carpentier A. Latissimus dorsi dynamic cardiomyoplasty. Ann Thorac Surg. 1989;47:600–4.PubMedCrossRefGoogle Scholar
  74. 74.
    Taguchi S, Mori A, Suzuki R, Ishida O. Technique for using pedicled latissimus dorsi muscle flaps to wrap prosthetic grafts in an infected thoracic aorta. Ann Vasc Surg. 2013;27:1223–7.PubMedCrossRefGoogle Scholar
  75. 75.
    Sedivy P, Spacek M, El Samman K, et al. Endovascular treatment of infected aortic aneurysms. Eur J Vasc Endovasc Surg. 2012;44:385–94.PubMedCrossRefGoogle Scholar
  76. 76.
    Semba CP, Sakai T, Slonim SM, et al. Mycotic aneurysms of the thoracic aorta: repair with use of endovascular stent-grafts. J Vasc Interv Radiol. 1998;9:33–40.PubMedCrossRefGoogle Scholar
  77. 77.
    Chen YX, Liu CW, Li YJ, et al. Endovascular repair of descending aortic pseudoaneurysms. Zhonghua wai ke za zhi [Chinese J Surg]. 2011;49:897–902.Google Scholar
  78. 78.
    Ting AC, Cheng SW, Ho P, Poon JT. Endovascular stent graft repair for infected thoracic aortic pseudoaneurysms—a durable option? J Vasc Surg. 2006;44:701–5.PubMedCrossRefGoogle Scholar
  79. 79.
    Moulakakis KG, Sfyroeras GS, Mylonas SN, et al. Outcome after preservation of infected abdominal aortic endografts. J Endovasc Ther. 2014;21:448–55.PubMedCrossRefGoogle Scholar
  80. 80.
    Maze MJ, Laws P, Buckenham T, et al. Outcomes of infected abdominal aortic grafts managed with antimicrobial therapy and graft retention in an unselected cohort. Eur J Vasc Endovasc Surg. 2013;45:373–80.PubMedCrossRefGoogle Scholar
  81. 81.
    Tossios P, Karatzopoulos A, Tsagakis K, et al. Successful surgical in situ treatment of prosthetic graft infection by staged procedure after Bentall operation and total aortic arch replacement. Springerplus. 2014;3:172.PubMedPubMedCentralCrossRefGoogle Scholar
  82. 82.
    Takano T, Terasaki T, Wada Y, Seto T, Fukui D, Amano J. Treatment of prosthetic graft infection after thoracic aorta replacement. Ann Thorac Cardiovasc Surg. 2014;20:304–9.PubMedCrossRefGoogle Scholar
  83. 83.
    Tossios P, Karatzopoulos A, Tsagakis K, et al. Treatment of infected thoracic aortic prosthetic grafts with the in situ preservation strategy: a review of its history, surgical technique, and results. Heart Lung Circ. 2014;23:24–31.PubMedCrossRefGoogle Scholar
  84. 84.
    Suzuki T, Kawamoto S, Motoyoshi N, et al. Contemporary outcome of the surgical management of prosthetic graft infection after a thoracic aortic replacement: is there a room to consider vacuum-assisted wound closure as an alternative? Gen Thorac Cardiovasc Surg. 2015;63:86–92.PubMedCrossRefGoogle Scholar
  85. 85.
    Lawrence PF. Conservative treatment of aortic graft infection. Semin Vasc Surg. 2011;24:199–204.PubMedCrossRefGoogle Scholar
  86. 86.
    Yamanaka K, Omura A, Nomura Y, et al. Surgical strategy for aorta-related infection. Eur J Cardiothorac Surg. 2014;46:974–80.PubMedCrossRefGoogle Scholar
  87. 87.
    Charlton-Ouw KM, Sandhu HK, Huang G, et al. Reinfection after resection and revascularization of infected infrarenal abdominal aortic grafts. J Vasc Surg. 2014;59:684–92.PubMedCrossRefGoogle Scholar
  88. 88.
    Buchholz HW, Engelbrecht H. Depot effects of various antibiotics mixed with Palacos resins. Chirurg. 1970;41:511–5.PubMedGoogle Scholar
  89. 89.
    Kretlow JD, Brown RH, Wolfswinkel EM, et al. Salvage of infected left ventricular assist device with antibiotic beads. Plast Reconstr Surg. 2014;133:28–38.CrossRefGoogle Scholar
  90. 90.
    Stone PA, Armstrong PA, Bandyk DF, et al. Use of antibiotic-loaded polymethylmethacrylate beads for the treatment of extracavitary prosthetic vascular graft infections. J Vasc Surg. 2006;44:757–61.PubMedCrossRefGoogle Scholar
  91. 91.
    Charlton-Ouw KM, Kubrusly F, Sandhu HK, et al. In vitro efficacy of antibiotic beads in treating abdominal vascular graft infections. J Vasc Surg. 2015;62:1048–53.PubMedCrossRefGoogle Scholar
  92. 92.
    Inafuku H, Senaha S, Morishima Y, et al. Infected thoracoabdominal aortic aneurysms including the major abdominal branches in 4 cases. Ann Thorac Cardiovasc Surg. 2008;14:196–9.PubMedGoogle Scholar
  93. 93.
    Coselli JS, Koksoy C, LeMaire SA. Management of thoracic aortic graft infections. Ann Thorac Surg. 1999;67:1990–3.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  • Rana O. Afifi
    • 1
  • Kristofer M. Charlton-Ouw
    • 1
  • Hazim J. Safi
    • 1
  • Anthony L. Estrera
    • 1
    Email author
  1. 1.Department of Cardiothoracic and Vascular SurgeryMcGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)HoustonUSA

Personalised recommendations