Endograft Infections after Complex Endovascular Aortic Repair

OBJECTIVE: Aortic endograft infection (AeGI) is a rare complication following complex endovascular aortic repair (cEVAR). Data on its incidence, risk factors, and outcomes are limited to very small case series. This study aimed to retrospectively determine the incidence and risk factors for AeGI after cEVAR and to describe treatment strategies and outcomes in a high volume aortic centre. METHODS: Patients undergoing cEVAR with fenestrated or branched endografts at Uppsala University Hospital, Sweden, between September 2010 and May 2024 were retrospectively identified and 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 included incidence, microbiology, treatment strategies, survival, and long term infection status. RESULTS: Among 527 patients (542 cEVARs, median follow up 47.4 months), 19 developed MAGIC diagnosed AeGI. The 5 year incidence was 3.87% (3.16% for non-infected aortic pathology and 23.5% for cEVAR treated primary infected aortic pathology [MAA]) adjusting for mortality as a competing risk using the cumulative incidence function. Independent risk factors to develop AeGI were MAA as index pathology (hazard ratio 10.2, 95% confidence interval 3.1 - 33.2) and late aortic related re-interventions (hazard ratio 3.0, 95% confidence interval 1.1 - 7.9). Six patients (32%) had a secondary fistula, associated with poor median survival (4.0 vs. 41.5 months). Treatment strategies were predominantly graft persevering: antimicrobial therapy alone in 11 of 19 (58%) or combined with image guided drainage and/or surgical debridement in seven of 19 (37%). At last follow up, remission or cure was achieved in 56%, 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 MAA as the index pathology and late aortic re-interventions. Prognosis is poor in patients with secondary fistula. Endograft preserving strategies may achieve infectious remission and survival in selected patients, not amenable to explantation, without fistula.