Outcomes after surgical management of suprarenal and thoracoabdominal aortic infections.

Abstract

Outcomes after the operative management of suprarenal and thoracoabdominal aortic infections are poorly characterized owing to their rare presentation and the high associated morbidity and mortality. Surgical treatment involves debridement of infected tissues and removal of native aortic or prosthetic material, as well as revascularization of renal, mesenteric, and lower extremity vessels. This study reports our experience with the surgical management of suprarenal and thoracoabdominal aortic infections and provides technical insights, as well as nuances of perioperative decision-making that are important for achieving acceptable outcomes. We conducted a single-center retrospective review of consecutive patients undergoing surgery for primary and secondary suprarenal or thoracoabdominal infections from 2002 to 2021. Patients with isolated thoracic, juxtarenal, or infrarenal aortic infections, or those managed with medical or endovascular therapy, were excluded. The primary end point was 30-day mortality. Secondary outcomes included complications, reintervention, and survival. Kaplan-Meier methodology was used to estimate reintervention and survival. A total of 56 patients were included (mean age, 65 ± 13 years; 79% male). Rupture was present in 57% (n = 32), and 20% (n = 11) had an aortoenteric fistula. Staphylococcus aureus was the most commonly isolated monomicrobial organism (n = 14 [25%]). In situ reconstruction was performed in 82% (n = 46) using various conduits (antibiotic-soaked prosthetic graft [n = 39 (70%)], cadaveric allograft [n = 4 (7%)], or femoral-popliteal vein [n = 3 (5%)]). Extra-anatomical bypass with aortic ligation was performed in 14% (n = 8). Reconstruction used an antegrade approach in 77% (n = 43), with a mean of 2.1 ± 1.3 revascularized vessels (67 renal, 30 superior mesenteric, and 15 celiac artery). Renal and/or celiac artery ligation occurred in 36% (n = 20) of patients. The 30-day mortality was 16% (n = 9), including two intraoperative deaths (4%). Major complications included renal failure (n = 11 [20%]), hemorrhage (n = 9 [16%]), respiratory failure (n = 8 [14%]), and graft thrombosis (n = 5 [9%]). Recurrent infection occurred in 5% (n = 3). Compared with secondary infections, primary infections were more likely to present with rupture (76% vs 37%; P = .008), but less likely to have concurrent aortoenteric fistula (3% vs 37%; P = .005). Primary infections also involved more renal/visceral reconstructions (2.5 ± 1.4 vs secondary, 1.7 ± 1.2; P = .02). No significant differences were observed between primary and secondary infections in 1-year survival (58 ± 10% vs 66 ± 9%; log-rank P = .9) or freedom from reintervention (51 ± 10% vs 60 ± 10%; log-rank P = .5). Suprarenal and thoracoabdominal aortic infections are rare, and although operative management results in considerable morbidity, perioperative mortality remains acceptable. Distinct differences in clinical presentations were observed between primary and secondary infections. With a tailored approach to reconstruction configuration and conduit selection, comparable outcomes can be achieved regardless of infectious etiology. However, reintervention is common, underscoring the need for vigilant postoperative surveillance.