Abstract
Background
Although rare, endograft infection is a severe complication of endovascular aneurysm repair (EVAR), usually requiring open endograft explantation and aortic reconstruction. This single-center retrospective series analyzed 9 consecutive patients who underwent EVAR explantation for infection from 2004 to 2023.
Case Summary
EVAR infection was diagnosed a median of 10 months (IQR: 3.25-21.5 months) after EVAR implantation. Eight patients underwent in situ reconstruction with physician-made bovine pericardial grafts, and in 1 patient, a silver-impregnated prosthetic graft was used. Two patients died within 30 days. One aortic reintervention was necessary owing to bleeding. Median follow-up was 10.5 months (IQR: 5-54 months). Two patients died during follow-up, but there were no aortic-related complications except for 1 reinfection in the patient who had been treated with a silver-impregnated prosthetic graft.
Conclusions
Despite the relevant perioperative morbidity and mortality associated with EVAR infection, endograft explantation and in situ reconstruction with preferably bovine pericardial grafts may offer definitive treatment of infection, with promising mid- and long-term results.
Key words: abdominal aortic aneurysm (AAA), endograft infection, endovascular aneurysm repair (EVAR, ), EVAR explantation, physician-made bovine pericardial grafts
Graphical Abstract
The treatment of abdominal aortic aneurysms using endovascular aneurysm repair (EVAR) has increased exponentially given its low perioperative morbidity and shorter recovery time.1 With an incidence of up to 2.3%,1, 2, 3, 4 endograft infection is a rather rare but life-threatening complication of EVAR, and it has a mortality rate of almost 100% if untreated.1,5 For diagnosis, the Management of Aortic Graft Infection Collaboration (MAGIC) has established uniform criteria, which include clinical, laboratory, and imaging findings.5,6 In addition to adequate antimicrobial therapy, surgical treatment is indispensable for definite eradication of the infection. Endograft explantation and in situ reconstruction warrant long-term success in patients fit for surgery.1,3 Here, we present our experience of 20 years in the surgical treatment of infected endografts.
Take-Home Messages
-
•
Endograft infection after EVAR is rare but represents a potentially fatal complication if left untreated.
-
•
Definitive treatment requires complete removal of the infected endograft and debridement of infected tissues, followed by in situ aortic reconstruction, alongside appropriate antimicrobial therapy.
-
•
No late reinfections were observed among patients reconstructed with bovine pericardial grafts. In accordance with the literature, these findings support the use of bovine pericardial grafts as a durable, infection-resistant option for in situ reconstruction in contaminated fields.
History of Presentation
A total of 870 patients underwent EVAR at the University Hospital of Bern between 2004 and 2023; of these cases, 751 were elective and 119 were emergent. Of the 60 EVAR conversions during the study period, 9 were due to endograft infection, including 2 cases in which EVAR had been performed in another hospital. All 9 patients were male, with a median age of 78 years (IQR: 68-80.5 years) at the time of EVAR infection. Comorbidities were frequent, and 6 of the 9 patients had undergone emergent EVAR (Table 1). The MAGIC criteria for the diagnosis of endograft infection were met by 8 of the 9 patients (Table 2). One patient only met 2 minor MAGIC criteria (positive blood cultures and fever). He had undergone EVAR for a penetrating aortic ulcer, and postoperative computed tomography showed rapid progression of the aneurysm sack without air. Therefore, it was considered a primarily infective native aortic aneurysm/penetrating aortic ulcer, falsely treated by EVAR. The median time from EVAR implantation to infection diagnosis was 10 months (IQR: 3.25-21.5 months).
Table 1.
Characteristics of the Patients
| Patients (all male), n | 9 |
| Age at EVAR infection, y, mean ± SD | 75 ± 7 |
| Emergent EVAR, n | 6 |
| Hypertension, n | 8 |
| Diabetes mellitus type 2, n | 4 |
| Chronic kidney disease, n | 3 |
| Chronic obstructive pulmonary disease, n | 4 |
| Current smoker, n | 1 |
EVAR = endovascular aneurysm repair.
Table 2.
Preoperative Description of Patients Diagnosed With EVAR Infection
| Patient # |
|||||||||
|---|---|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |
| Major criteria | |||||||||
| Aortoenteric fistula | – | + | – | – | – | – | – | – | – |
| Pus in aneurysm sac | – | + | + | – | + | + | + | – | + |
| CT confirmed | + | + | + | + | + | – | – | + | – |
| Organisms recovered from graft | – | + | – | – | + | + | – | – | + |
| Minor criteria | |||||||||
| Fever | + | – | – | + | + | + | – | + | + |
| Positive blood cultures | + | – | + | – | + | – | – | + | – |
| Other | |||||||||
| Abdominal pain | – | – | + | + | + | – | + | + | + |
| Other infectious symptomsa | – | – | + | + | – | – | + | – | – |
CT = computed tomography; EVAR = endovascular aneurysm repair.
1 pyelonephritis and diarrhea, pneumonia, and spondylodiscitis.
In all patients, the operative approach was a median laparotomy with removal of all endovascular material, thorough debridement of the surrounding tissue, and aortoiliac in situ reconstruction. In selected cases, the suprarenal struts of the endograft were left in situ when deemed too high risk to remove. Suprarenal clamping was necessary in 3 of 9 patients, and supraceliac balloon occlusion in 2 of 9 patients. In situ reconstruction was performed with a physician-made bifurcated bovine pericardial graft in 8 patients (Figures 1 and 2) and with a silver-impregnated prosthetic graft in 1 patient. Coverage of the new graft using a pedicled omentum flap was used in 6 patients (Figure 3). One patient had an aortoenteric fistula and additionally required iliac vein repair with direct suture, sigmoid resection, and colostomy. No additional procedures were performed in the remaining patients during EVAR explantation.
Figure 1.
Bifurcated Graft Constructed From an Off-the-Shelf Bovine Pericardial Patch
(A, left) The width of the required patch is determined by multiplying the desired diameter by π and adding 2 to 3 mm for suturing. (B, right) The graft is sewn with a nonabsorbable 4-0 polypropylene running suture.
Figure 2.
Intraoperative Images of the Surgical Site
Intraoperative images showing (A, left) the infected EVAR graft and (B, right) the bifurcated bovine pericardial graft reconstruction after removal of all infected tissue. EVAR = endovascular aneurysm repair.
Figure 3.
Omentoplasty With Pedicled Omentum Covering the Aortic Graft Reconstruction
Two patients died within 30 days of EVAR explantation. One was the patient mentioned earlier who required iliac vein repair. Despite adequate postoperative heparinization, this patient experienced massive left-sided pulmonary embolism, myocardial infarction, and acute limb ischemia caused by thromboembolic occlusion of the superficial femoral and popliteal artery requiring thrombectomy. The patient died on postoperative day 5 after multiorgan failure. The other patient had undergone double-chimney EVAR 4 years before. He required urgent replacement of the complete abdominal aorta and iliac arteries with a bifurcated pericardial graft, including reimplantation of the visceral arteries, venous bypasses to both renal arteries, followed by open abdomen treatment owing to endograft infection with impending rupture. Postoperatively, cholecystectomy was performed for gallbladder hydrops, followed by initial clinical improvement. On postoperative day 17, hemorrhagic shock with cardiac arrest occurred, necessitating urgent revision for proximal anastomotic and diffuse graft bleeding; further revisions controlled recurrent bleeding from the lumbar arteries, the liver capsule, and the abdominal wall, with negative intraoperative cultures under ongoing antibiotic therapy. Given the prolonged need for ventilation, tracheostomy was performed. On postoperative day 28, the patient experienced abrupt neurological decline, likely due to ischemic stroke. Active treatment was then withdrawn, and the patient died.
No other aortic reinterventions were necessary within 30 days. In total, 3 reoperations were necessary for other reasons: 1 cholecystectomy (in the aforementioned patient with biliary hydrops), 1 spondylodesis required for spondylodiscitis, and 1 intraperitoneal onlay-mesh repair for evisceration. Other perioperative complications are listed in Table 3.
Table 3.
Peri-operative and Postoperative Outcomes of Patients Undergoing EVAR Explantation for Infection
| 30-Day Complications | n |
|---|---|
| Death | 2 |
| Cardiac | 4 |
| Pulmonary | 2 |
| Gastrointestinal | 2 |
| Renal insufficiency | 5 |
| Permanent dialysis, n | 0 |
| Bleeding | 1 |
| Follow-up complications | |
| Late death | 2 |
| Late rupture | 0 |
| Reinfection | 1 |
EVAR = endovascular aneurysm repair.
Causing pathogens were identified in 7 of the 9 patients, of whom 4 had an infection with multiple pathogens (Table 4). The 2 patients in whom no pathogen could be identified had prolonged antimicrobial therapy prior to EVAR explantation (treating severe pyelonephritis and psoas abscess), likely accounting for the negative cultures. Postoperatively, antimicrobial treatment was administered according to antibiograms in those with identified pathogen. Median duration of antimicrobial therapy in the 7 patients surviving the perioperative period was 22 weeks (IQR: 12-76 weeks).
Table 4.
Heterogeneous Pathogen Profile of the Intraoperative Bacterial Sampling
| Patient # | Pathogens |
|---|---|
| 1 | Methicillin-susceptible and -resistant Staphylococcus aureus, Candida albicans, Serratia marcescens, and Enterococcus faecalis |
| 2 | Bacteroides fragilis, Streptococcus milleri, extended-spectrum beta-lactamase Escherichia coli, and Pseudomonas |
| 3 | Klebsiella pneumonia and coagulase-negative Staphylococcus |
| 5 | Beta-hemolytic group C Streptococcus |
| 6 | Coagulase-negative Staphylococcus |
| 8 | Escherichia coli |
| 9 | Escherichia coli and Enterococcus faecalis |
Patients 4 and 7did not show any growth of specimens in cultures, probably owing to prolonged preoperative antimicrobial treatment.
Median follow-up after EVAR explantation was 10.5 months (IQR: 5-54 months) for 6 patients with regular clinical and radiological surveillance. One patient was lost to follow-up immediately after hospital discharge. Two patients died during follow-up after 6 and 11 years, one from myocardial infarction; the other patient was the one treated with a silver-impregnated prosthetic graft. He had a reinfection 7 years after EVAR explantation and underwent re-reconstruction with a bovine pericardial graft. He died 4 years after bovine reconstruction at the age of 85 years of an unknown cause, 1 year after the last follow-up showing no signs of reinfection. No graft-related complications, no aortic reinterventions, and no reinfections were observed in the remaining patients.
Discussion
The diagnosis and management of EVAR infection remain a challenge, often leading to high morbidity and mortality.2,4,5 Our analysis demonstrated a very low incidence of EVAR infection over 20 years (<1%). The majority of infections occurred after emergent EVAR. This has also been reported by Järvinen et al,2 and it may be due to limited sterile preparation time, patient instability, suboptimal antibiotic prophylaxis, or even an undiagnosed primary infection in the emergency setting. In retrospect, 2 of our 9 patients with endograft infection likely had an infected native aortic aneurysm that was overlooked in the emergency setting of a contained rupture.
According to the literature, the most frequently identified pathogens are Gram-positive bacteria (Enterococcus, Staphylococcus aureus, coagulase-negative Staphylococcus) in 58% of the cases, and about 34% are Gram-negative bacteria. Our findings revealed a more heterogeneous pathogen profile, making hospital hygiene–related sources of infection less likely.
Relevant perioperative morbidity and mortality was observed, although generalizable conclusions cannot be drawn given the small sample size. Nevertheless, this is in accordance with the literature, with reported mortality rates of up to 57%,2, 3, 4, 5 reflecting the gravity of endograft infections and associated complications. One patient in our series required revision of the proximal anastomosis of the bovine pericardial graft because of bleeding in the early postoperative phase. Although all subsequent cultures were negative and the patient suffered from multiple other hemorrhagic events, the bleeding from the anastomosis may have been due to (persistent) infection, that is, treatment failure.
Beyond the early postoperative period, endograft explantation and in situ reconstruction with bovine pericardial grafts, combined with adequate antimicrobial therapy, have the potential for definitive treatment of EVAR infection without reinfection or graft-related complications. The only observed reinfection was in the one patient who had been treated with a prosthetic graft. Although the findings of this series are limited not only by the small sample size but also because of the limited follow-up, the favorable long-term performance of physician-made bovine pericardial grafts has been confirmed in a recent multicenter study.4 Therefore, in patients fit for surgery, EVAR explantation and in situ reconstruction with a bovine pericardial graft should be considered as a primary option. Although reported reinfection rates and graft-related complication rates are low,4 they may remain a concern, making long-term follow-up of these patients of utmost importance.
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
References
- 1.Wanhainen A., van Herzeele I., Goncalves F.B., et al. European Society for Vascular Surgery (ESVS) 2024 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms. Eur J Vasc Endovasc Surg. 2024;67(2):192–331. doi: 10.1016/j.ejvs.2023.11.002. [DOI] [PubMed] [Google Scholar]
- 2.Järvinen I., Heinola I., Kantonen I., Aho P., Vikatmaa P., Venermo M. Two-decade single-center experience with graft infections after infrarenal endovascular aortic repair. Ann Vasc Surg. 2025;120:46–56. doi: 10.1016/j.avsg.2025.04.132. [DOI] [PubMed] [Google Scholar]
- 3.Javairiah F., Duncan A.A., de Grandis E., et al. Treatment strategies and outcomes in patients with infected aortic endografts. J Vasc Surg. 2013;58(2):371–379. doi: 10.1016/j.jvs.2013.01.047. [DOI] [PubMed] [Google Scholar]
- 4.Weiss S., Mallorqui M.H., Czerny M., et al. Physician made bovine pericardial tube grafts in aortic infection: a European multicentre study. Eur J Vasc Endovasc Surg. 2024;67(6):997–1005. doi: 10.1016/j.ejvs.2024.02.004. [DOI] [PubMed] [Google Scholar]
- 5.Chakfé N., Diener H., Lejay A., et al. Editor's choice – European Society for Vascular Surgery (ESVS) 2020 clinical practice guidelines on the management of vascular graft and endograft infections. Eur J Vasc Endovasc Surg. 2020;59(3):339–384. doi: 10.1016/j.ejvs.2019.10.016. [DOI] [PubMed] [Google Scholar]
- 6.Lyons O.T., Baguneid M., Barwick T.D., et al. Diagnosis of aortic graft infection: a case definition by the Management of Aortic Graft Infection Collaboration (MAGIC) Eur J Vasc Endovasc Surg. 2016;52(6):758–763. doi: 10.1016/j.ejvs.2016.09.007. [DOI] [PubMed] [Google Scholar]