Aortic Endograft Infection: Timely Recognition Is Key

A 29-year-old male with Marfan’s syndrome presented to the hospital with fatigue and rigors. Two years earlier, he had a type A ascending aortic dissection and underwent valve sparring aortic root and ascending aortic and hemiarch replacement. On exam, he was febrile to 39.3°C, tachycardic at 120 BPM with normal blood pressure. There was no audible murmur.

An echocardiogram showed preserved left ventricular function and no significant valvular abnormalities. A chest CT angiography (CTA) demonstrated stable chronic dissection flap extending from the ascending aorta into the aortic arch and intact prosthetic aortic graft without evidence of infection (Figures 1A and 1B). Blood cultures taken on admission were positive for methicillin sensitive Staphylococcus aureus (MSSA). He was started on broad spectrum IV antibiotics and bacteremia cleared on hospital day 3; however, he had persistent low-grade fever. Given concern for seeding of aortic endograft, a CTA was repeated on hospital day 6 and demonstrated a new fluid collection with surrounding wall enhancement and thickening being a concern for abscess related to evolving graft infection (Figures 1C–E).

Figure 1: CT Angiography Imaging of Aortic Endograft Pre- and Post-redo Surgery.

A: Admission CT angiography (CTA) demonstrating intact prosthetic aortic graft (blue arrow), with stenosis distally (green arrow). B: 3D reconstruction of ascending aorta showing aortic graft (blue arrow). C, D: Coronal CTA images demonstrating fluid collection encasing the ascending aortic graft (red arrow) with contrast extravasation through the graft (yellow arrow), wall thickening around left main coronary artery (green arrow). E: Axial view of ascending aorta showing fluid collection (red arrows) and prior stable dissection. F: Gross image of the distal aortic graft post extraction. G: Coronal view of the aorta with newly implanted endograft demonstrating resolution of the fluid collection.

The patient underwent urgent endograft explantation, debridement, and redo ascending aorta and hemiarch replacement with a 28 mm Gelweave graft with preservation of the aortic valve (Figure 1F). The prosthetic graft was cultured and grew MSSA. He recovered well and repeat CTA 3 days post-op demonstrated resolution of fluid collection (Figure 1G). The patient was discharged on a 6-week course of IV nafcillin. A repeat outpatient CTA after completion of antibiotics showed no evidence of infection and preserved aortic endograft.

This case demonstrates the rapid progression of an aortic endograft infection that was not initially identified on imaging a few days prior. Redo surgical repair of infected aortic endografts carries a high risk of mortality if prompt and adequate source control is not achieved.[1,2]

In our patient, the prompt recognition of endograft infection prevented the spread of infection to the aortic valve and enabled the patient to undergo another aortic valve sparring root replacement, which, given his young age, will dramatically improve his long-term prognosis. Physicians should remain vigilant for endovascular graft infection when evaluating bacteremic patients with prior aortic endograft repair.