Open conversion for endograft infection using the Ovation Alto endograft

• First reported infection case involving the Ovation Alto stent graft post-EVAR • Partial explant with mid-crown proximal control achieved infection control • Case underscores need for individualized management of EVAR graft infections The Ovation Alto device exhibits unique adaptive sealing owing to its polymer-filled sealing ring and has a large bare stent on the proximal side with no stent in the main body portion. We report a case of device infection after endovascular aneurysm repair (EVAR) using the Ovation Alto device. An 85-year-old man with a history EVAR using the Ovation Alto for abdominal aortic aneurysm (AAA) presented two years postoperatively with fever and pyogenic arthritis. Imaging revealed an enlarged AAA, a new type II endoleak, and periaortic inflammation. Laboratory findings showed elevated inflammatory markers, and Streptococcus dysgalactiae was detected in synovial fluid. A diagnosis of endograft infection and septic arthritis was made. Open conversion was performed via laparotomy. Proximal aortic control was achieved at the mid-crown above the renal arteries, and the distal stent graft leg was removed. Extensive debridement was performed, followed by graft replacement and omental wrapping. The fabric portion was explanted, while the bare stent was left in situ. Postoperatively, the patient underwent arthroscopic debridement and local antibiotic therapy for septic arthritis, followed by systemic antibiotics. Although the patient’s infection was controlled, he was ultimately diagnosed with advanced colorectal cancer with liver metastases, leading to death six months after surgery. This case highlights the complexity of managing stent graft infections after EVAR with the Ovation Alto. While complete device explantation may not always be feasible due to anatomical constraints, tailored surgical strategies can achieve infection control.