Infected Aneurysms: Causes, Treatment & Outcome in Vascular Surgery

1. Μυκωτικά Ανευρύσματα – Μόλυνση Ενδοπρόθεσης Κωνσταντίνος Γ. Μουλακάκης Επιμελητής AΑγγειοχειρουργός, Αγγειοχειρουργική Κλινική, “ Aττικόν” Νοσοκομείο 2015

2. "infected aneurysm" has gradually replaced the original designation "mycotic aneurysm“

3. Μυκωτικά Ανευρύσματα – Αιτιολογία και Παράγοντες Κινδύνου • Βακτηριακή Ενδοκαρδίτιδα (σηπτικά έμβολα) • Αρτηριακό Τραύμα, ή τραύμα του ενδοθηλίου (Τοξικομανείς, Στεφανιογραφίες, ΧΝΑ) • Φλεγμονή, Μικροβιαιμία (Ουρολοίμωξη, Πνευμονία, Εκκολπωματίτιδα) • Διασπορά από Φλεγμονή περιξ της αορτής (σπονδυλίτιδα, γαστρεντεριτιδα με προσβολή παραορτικών λεμφαδένων) • Διαταραχές ανοσοποιητικού συστήματος (70%) • Αθηροσκλήρωση (αποικισμός πλακών από μικρόβια)

5. Ο ρόλος της ενδαγγειακής αποκατάστασης στη θεραπεία των Μυκωτικών ανευρυσμάτων

6. Εμπλεκόμενοι Μικροοργανισμοί Θετικές Καλλιέργειες ≈62 % • Staphylococcus sp. 20 % • Salmonella 12 % • Streptococcus sp. 11 % • Other 19 % (Pseudomonas aeruginosa, E coli, Enterobacteriumfaecium, Prot. mirabilis, Serratiasonticola, Bacteroidesfr., Bacillus cereus, Tuberculous species, Listeria monocytogenes, Coxiellabruneti, Candida albicans) ↑f Sörelius K, Mani K, Björck M, Sedivy P, Wahlgren CM, Taylor P, Clough RE, Lyons O, Thompson M, Brownrigg J, Ivancev K, Davis M, Jenkins MP, RancicZ, Mayer D, Brunkwall J, Gawenda M, Kölbel T, Jean-Baptiste E, Moll F, Berger P, Liapis CD, Moulakakis KG, LarzonT, Pirouzram A, Wanhainen A; European MAA collaborators. Endovascular treatment of mycotic aortic aneurysms: a European multicenter study. Circulation. 2014

7. Clough EJVES 2009

8. European multicenter studyof MAA 16 European centers from 8 countries , 1999 - 2013 123 patients Attikon Hospital

9. European multicenter studyof MAA 123 patients • Kaplan–Meier analysis • 1-month survival was 91% • 3-month 86% • 1-year 76% • 5-year 55% • 10-year 41% Mean follow-up time was 35 months (range 1 week to 149 months)

10. Infection-related complications • A 27% developed an infection-related complication, of whom 70% died (19%of the total cohort) • 30 % of these infection-related complications occurred within 30 days • 52% within 90 days and 82% within 1 year

11. 81.3% 50% 40.6% • 30-day Mortality 19% (6/32) • Recurrence of infection and death in 5 more pts (19%) • Overall, 1-year Mortality 41% Pts with aneurysms situated in central parts of the thoracic and infrarenal aorta had better death/survival than among patients with a proximal or distal aneurysm location.

12. J VascSurg 2011 • 21 patients, 17 abdominal and four thoracic infected aortic aneurysms • 5 patients presented with fistulas • The overall in-hospital mortality was 19% (4/21) • 60% (3/5) in the fistula group and only 6% (1/16) in the nonfistula group. • There were no deaths in the 15 patients of the nonfistula group with an average patient follow-up of 22 months (range, 1-54)

13. 673 AAA – 19 (2.8%) infected • 6 RAA (32%) • 15 (79%) positive blood cultures • Staphylococcus aureus (+) Clough RE, et al. Is endovascular repair of mycotic aortic aneurysms a durable treatment option? Eur J VascEndovasc Surg. 2009

14. 30-day mortality = 11% • Survival 20 months = 73% • All 8 deaths aneurysm related! Overall Mortality in follow-up 42% Patients presented with fistula had a worse outcome

15. 27 patients 3-year survival 58.4% Patel JVS 2010

16. Important Issues • Comparison, Endovascular vs. Open • Predictors of perioperative mortality and fatal infection complications in pts treated with Endovascular repair • When is endovascular Repair the preferred definitive Therapy? • Keys to Increase the Efficacy and success of Endovascular Treatment for Aortic Infections

17. 1. Endovascular vs. Open Repair Endovascular repair Lower 30d/In Hospital Mortality BUT Higher Follow-up Infection related Mortality

18. Endografts for the treatment of Infected Aortic Aneurysms • Less Invasive • Decreased surgical morbidity and mortality • Prompt control of bleeding in the face of hemodynamic instability • An alternative for critically ill patients with hostile abdomen • Retained foreign body in infected tissue • Uncertain long term outcomes?

19. 2. Predictorsof perioperative mortality and fatal infection complications in pts treated with Endovascular repair • Presentation with severe sepsis • Periaortic/ intrathrombus gas on preoperative CT scan • Advanced Age • Positive blood cultures • Non-Salmonella positive blood cultures • Immunodefficiency • Presence of fistula • Thoracic MAAs SöreliusK, et al. ; European MAA collaborators. Endovascular treatment of mycotic aortic aneurysms: a European multicenter study. Circulation. 2014 Clough RE, et al. Is endovascular repair of mycotic aortic aneurysms a durable treatment option? Eur J VascEndovasc Surg. 2009 Kritpracha B, Premprabha D, Sungsiri J, Tantarattanapong W, RookkapanS, JuntarapatinP. Endovascular therapy for infected aortic aneurysms. J Vasc Surg. 2011

20. 3. When is endovascular Repair the preferred definitive Therapy? • Good response to preoperative antibiotic therapy • Absence of severe sepsis on presentation • Absence of Periaortic gas on preoperative CT scan, limited purulence or less virulent infection • Absence of fistula on presentation

21. 4. Keys to Increase the Efficacy and success of Endovascular Treatment for Aortic Infections • Broad spectrum antibiotics should administered as soon as a mycotic aneurysm is suspected • Prolonged postoperative antibiotic therapy • Additional procedures such as surgical debridement and percutaneous drainage are important adjuncts in eliminating the source of infection. 1. Moulakakis KG, Mylonas SN, Antonopoulos CN, Kakisis JD, Sfyroeras GS, Mantas G, Liapis CD. Comparison of treatment strategies for thoracic endograft infection. J Vasc Surg. 2014 2. Moulakakis KG, Sfyroeras GS, Mylonas SN, Mantas G, Papapetrou A, Antonopoulos CN, Kakisis JD, Liapis CD. Outcome after preservation of infected abdominal aortic endografts. J EndovascTher. 2014

22. CASE 1 4,8 cm 83 y Fever up to 38.5 °C Leukocytosis: 10.190 CRP: 136 Haemodynamic Instability, ↓ HgB Contained Rupture After 2 Days

23. EVAR Cook Zenith After 24 Hours septic shock Open laparotomy, drainage of the abscess, debridement around the endograft and irrigation with Garamycin

24. Abscess cultures St.Aureus Discharged Cloxacillin Sodium and Rifampycin 3 month follow-up Moulakakis KG, Sfyroeras GS, Kakisis JD, Papapetrou A, Antonopoulos CN, Mantas G, Brountzos EN, Liapis CD. Endograft infection and treatment with preservation of the endograft: early results in 3 cases. Ann Vasc Surg. 2014

25. CASE 2 Fever up to 39 ° C Leukocytosis ↑ CRP Thoracic pain Blood cultures (-) After 3 Days

26. TAA Diameter Increased TEVAR VALIANT, MEDTRONIC

27. After 3 Months Fever up to 39 ° C Leukocytosis ↑ CRP Esophagus stenting

28. Esophagectomy and Gastric pull Discharged Cloxacillin Sodium and Rifampycin

29. Endograft infection • Graft infection after endovascular aneurysm repair (EVAR or TEVAR) is an underrecognized and underreported event. • The incidence of aorto-iliac stent-graft infection ranges from 0.4% to 0.7% (1). • Although rare, it may have devastating consequences. • Mortality rates range from 25% to 100% (0.6% to 3% for open aortic graft infection 2,3) Setacci C. et al. Management of abdominal endograft infection. J Cardiovasc Surg. 2010 T.W. Swain, et al. Management of infected aortic prosthetic grafts. Vasc Endovascular Surg. 2004 S. O’Connor, et al. A systematic review and meta-analysis of treatments for aortic graft infection. JVS.2006

30. Pathogenesis • Bacterial inoculation during endovascular procedure • Pre-existing -mycotic aneurysm or inflammatory aneurysm-, could result in intestinal necrosis and fistula formation • Remote source of sepsis (eg, endocarditis, pneumonia, urinary tract infection) • Cancer or immunodeficiency • Repeated secondary procedures • Stent migration • Erosion of the aorta and the duodenum by embolization coils • Fabric rupture ?? • Erosion of the aorta by the hooks and barbs • Endoleak and endotension may lead to aorto-enteric fistula formation ?? Stent Graft Related Setacci C. et al. Management of abdominal endograft infection. J Cardiovasc Surg. 2010

31. Clinical Presentation Aortic Endograft Infection Thoracic Endograft Infection • Low grade infection • Systemic Sepsis • Aortoenteric Fistula (41%) • Abdominal or back Pain • Abscess (psoas) • Pseudonaurysm • Urinary tract infection • Low grade infection • Systemic Sepsis • Fistula (aortoesophageal or broncial) (38%) • Chest Pain • Abscess (periaortic) • Pseudonaurysm • Pneumonia, mediastinitis 52%% 50%% Numan F. et al. Management of endograft infections. J Cardiovasc Surg. 2011

32. Εμπλεκόμενοι Μικροοργανισμοί 20-83% αναγνωρίζεται και ταυτοποιείται ο υπεύθυνος μικροβιακός παράγοντας • St.Aureus 22% • Streptococcus sp. 11% • Multiple pathogens 21% • Candida Ablicans , Mycetes 6% • E.Coli • Enterococci • Pseudomonas, Serratia, Klebsiella, Ent.Cloacae ↑f Numan F. et al. Management of endograft infections. J CardiovascSurg . 2011 Setacci C. et al. Management of abdominal endograft infection. J Cardiovasc Surg. 2010

33. Διάγνωση μολυσμένου Μοσχεύματος • βαθμός υποψίας • Καλλιέργειες • Ενδοσκοπικός Ελεγχος (AEF) • CT / MR • PET CT • Πυρηνικός Ελεγχος ,Σπινθηρογράγημα

34. Management of Infected Endograft Depends on : • Patient’s clinical status • Co-morbidities • Presence of preoperative sepsis • Microorganisms involved

35. 1. ΑΝΟΙΚΤΗ ΧΕΙΡΟΥΡΓΙΚΗ ΑΝΤΙΜΕΤΩΠΙΣΗ

36. Management of Infected Endograft Graft Excision is the GOLD STANDARD • Graft Excision & Extra-anatomic bypass • Neo-aortoiliac System Procedure • In Situ Aortic Graft Replacement • (Homograft, Silver Graft) High mortality and morbidity rates, especially when undertaken in unstable, septic patients with severe comorbidities Variable results on patency and reinfection rates Fiorani P, et al. Endovascular graft infection: preliminary results of an international enquiry. JEVT 2003

43. JEVT 2010 Technique of Aortic stent-graft explantation Factors that may influence the feasibility of aortic stent-graft explantation • The fixation system (hooks or barbs) • the associated periaortic inflammatory reaction and endograft incorporation • the presence of any additional grafts, cuffs, or coils placed as secondary interventions

44. 2. ΠΑΡΟΧΕΤΕΥΣΗ, ΧΕΙΡΟΥΡΓΙΚΟΣ ΚΑΘΑΡΙΣΜΟΣ, ΔΙΑΤΗΡΗΣΗ ΤΟΥ ΜΟΣΧΕΥΜΑΤΟΣ

45. Management of Infected Endograft in High Risk patients for open repair • Surgical or CT-guided percutaneous placement of drains into the aneurismal sac abscess contiguous to the graft, in conjunction with irrigation of the perigraft area followed by appropriate antibiotic therapy Pryluck DS et al. Percutaneous drainage of aortic aneurysm sac abscesses following endovascular aneurysm repair.Vasc Endovascular Surg.2010 Deshmukh H. et al. Percutaneous management of complications (aortoenteric fistula and sac abscess) following bypass surgery for abdominal aortic aneurysm.CardiovascInterventRadiol. 2007 S.J. Hulin* and G.E. Morris .Eur J Vasc Endovasc Surg .2007 Promising results in patients without signs of severe sepsis

46. Management of Infected Endograft in High Risk patients for open repair • CT-guided percutaneous drainage followed by appropriate antibiotic therapy Pryluck DS et al. Percutaneous drainage of aortic aneurysm sac abscesses following endovascular aneurysm repair.Vasc Endovascular Surg.2010 Deshmukh H. et al. Percutaneous management of complications (aortoenteric fistula and sac abscess) following bypass surgery for abdominal aortic aneurysm.CardiovascInterventRadiol. 2007 S.J. Hulin* and G.E. Morris .Eur J Vasc Endovasc Surg .2007

47. Symptomatic 8.1 cm pararenal abdominal aortic aneurysm CASE 1 • A 63-year old man, smoker • Hostile abdomen • Previous MI • AF under oral anticoagulants • COPD • Severe obesity (BMI: 36.6) EVAR 1 month CT type-Ia endoleak multiple coils were deployed followed by biological glue infusion resulting in successful type Ia endoleak treatment….BUT

48. Eight months later…. Endograft Infection Fever up to 39,4 C Lower back Pain Leucocytosis Increased CRP CTA Presence of air in the aneurysm sac cavity Blood Cultures: E.Coli and Ent. Faecalis

49. Mini-Laparotomy : Sigmoid detached from the inflammatory mass, omentoplasty. Percutaneous continuous drainage of aortic aneurysm sac abscess for 15 days • CT- guided percutaneous continuous drainage followed by Vancomycin intrasac administration for 15 days • Oral administration of moxifloxacin ( 400 mg daily dose x 30d)

50. Follow-up at 18 months CTA :No presence of air in the sac cavity Decrease of aneurysm sac diameter Patient remains asymptomatic, afebrile. WBC : 5.300, CRP:9