Aortoiliac stent graft infection: Current problems and management

Aortic stent graft infection is uncommon. Most cases have been described anecdotaly in single-case reports. After observing one case in our experience, we decided to review the literature and contact centers performing endovascular aortic repair to determine the frequency, risk factors, and current treatment of stent graft infection. The literature was reviewed and the authors of identified articles were contacted for further information. In addition, 40 centers specializing in endovascular treatment were contacted by means a dedicated questionnaire. A total of 65 aortic stent graft infections were identified, including 43 reported cases and 22 previously unpublished cases that were observed at specialized centers. Stent grafts were implanted in the aorta in 50 cases and in the iliac artery in 15 cases. The frequency of infection was 0.43%. The gender ratio was 4:1 (M:F). Twenty-three percent of patients had immunodeficiency factors. Placement was performed in an interventional radiology suite in 62.5% of cases and in a sterile operating theater in 37.5%. Also, 35.5% of patients underwent other vascular procedures during the course of study and 29.2% stent grafts benefited from adjuvant endovascular procedures. Infection was classified as low grade in 35.4% of patients and high grade in 64.6%. Thirty-one percent of infections were associated with aortoenteric fistula. The offending microorganism was Staphylococcus aureus in 54.5% of cases. Treatment was conservative in 18% of cases and surgical in 82%. Surgical treatment consisted of stent graft removal followed by either extraanatomical bypass (59.5%) or in situ prosthetic reconstruction (40.5%). Mortality was 18% overall, 36.4% after conservative treatment and 14% after surgical treatment (p=0.083). Mortality was 16% after surgical treatment with extraanatomical bypass vs. 5.8% surgical treatment with in situ reconstruction. From these results we conclude that stent graft infection is an uncommon occurrence associated with poorly defined risk factors. Surgical treatment with complete excision of the infected stent graft followed by in situ reconstruction provides the best outcome. Establishment of a multicenter register to record such complications is needed to confirm the findings of this study.