Late outcomes of endovascular aortic repair for the infected thoracic aorta.

Abstract

Untreated infectious thoracic aortic pathology (ITAP) has a dismal prognosis. Despite its high rates of morbidity in this setting, conventional open repair remains the gold standard therapy. Understanding the limitations of open repair, we describe outcomes for one of the largest series of ITAP treated with thoracic endovascular repair. Of 170 patients undergoing thoracic endovascular repair (1993 to 2008), 20 presenting with ITAP were identified. Indications for intervention included aortobronchial (n = 10), aortoesophageal (n = 2), or aortocutaneous fistulae (n = 1), or mycotic aneurysms (n = 7). Underlying disease included fusiform aneurysm (n = 1), saccular aneurysm or pseudoaneurysm (n = 18), or dissection (n = 1). Four patients had ITAP from infected grafts. Follow-up was 100% complete (mean, 28.6 months). Median age was 73 years. A history of immunosuppression was present in 4; concurrent malignancy was present in 5. Arch repair was needed in 8; total descending, in 6. Three patients underwent hybrid thoracic endovascular repair or debranching procedures. Causes of in-hospital mortality (n = 3; 15.0%) included refractory hypoxemia (n = 1) and sepsis from tracheoesophageal fistula (n = 1) or pneumonia (n = 1). Dialysis was needed in 2; none sustained postoperative stroke or paraplegia. Mean Kaplan-Meier survival was 39.0 months. Late mortality was seen in 13 patients, with 3 attributed to recurrent ITAP. There was a trend for recurrence of ITAP when thoracic endovascular repair was originally performed in an infected graft (p = 0.08). At last imaging follow-up, 14 patients had a healed aorta. Treatment with thoracic endovascular repair for ITAP can be accomplished with acceptable results. Late mortality is frequently related to underlying comorbidities, rather than complications from the aortic disease itself, suggesting that thoracic endovascular repair is an appropriate palliative therapeutic option in this high-risk cohort.