Skip to main content

Advertisement

SpringerLink
Log in

Infections of the aorta

  • REVIEW ARTICLE
  • Published:
Indian Journal of Thoracic and Cardiovascular Surgery Aims and scope Submit manuscript

Abstract

Infection of the aorta continues to be a clinical challenge with high morbidity and mortality. The incidence varies between 0.6 and 2.6%. There has been a steady increase in graft infections, especially endograft infections, due to increased procedures (0.2 to 5%). Staphylococcus species remains the most common organism; however, gram-negative and rare causative agents are also reported. The clinical presentation can be very diverse and a high degree of suspicion is necessary to diagnose them. Sometimes, they may present as an emergency with rupture or fistulation. Diagnosis is based on a triad of clinical features, microbial cultures and imaging. Culture-specific antibiotics are mandatory during the entire course, but seldom cure alone. Surgical management remains the standard of care and involves an integrated approach involving debridement, reconstruction and use of adjuncts. Various aortic substitutes have been described with advantages and limitations. Pericardial tube grafts have emerged as a good option. Endo-vascular options are practiced mostly as a bridge to definitive surgery. A small role for conservative management is described. Aortic fistulation to the gut and airway carries a very high mortality. There are no large series in the literature to define guideline-directed treatment and most often it is a customized solution. The 30-day mortality remains close to 30%. Outcomes depend on multiple factors including patient’s age, the timing of presentation, diagnosis, causative organism, host status and the treatment strategy adopted.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10

Similar content being viewed by others

References

  1. Osler W. The gulstonian lectures, on malignant endocarditis. Br Med J. 1885;1:467–70.

  2. Sommerville RL, Allen EV, Edwards JE. Bland and infected arteriosclerotic abdominal aortic aneurysms: a clinicopathologic study. Medicine (Baltimore). 1959;38:207–21.

  3. Li HL, Chan YC, Cheng SW. Current evidence on management of aortic stent-graft infection: a systematic review and meta-analysis. Ann Vasc Surg. 2018;51:306–13.

  4. Manzur MF, Han SM. FAW. Infected arterial aneurysms. In: Sidawy NA, Perler AB, editors. Rutherford’s Vasc Surg Endovasc Ther. 9th ed. Philadelphia: Elsevier; 2019. p. 588–602.

  5. Wilson WR, Bower TC, Creager MA, et al. Vascular graft infections, mycotic aneurysms, and endovascular infections: a scientific statement from the American Heart Association. Circulation. 2016;134:e412–60.

  6. Oderich GS, Panneton JM, Bower TC, et al. Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results. J Vasc Surg. 2001;34:900–8.

  7. Dean RH, Waterhouse G, Meacham PW, Weaver FA, O’Neil JA. Mycotic embolism and embolomycotic aneurysms. Neglected lessons of the past. Ann Surg. 1986;204:300–7.

  8. Jarrett F, Darling RC, Mundth ED, Austen WG. Experience with infected aneurysms of the abdominal aorta. Arch Surg. 1975;110:1281–6.

  9. Müller BT, Wegener OR, Grabitz K, Pillny M, Thomas L, Sandmann W. Mycotic aneurysms of the thoracic and abdominal aorta and iliac arteries: Experience with anatomic and extra-anatomic repair in 33 cases. J Vasc Surg. 2001;33:106–13.

  10. Marques da Silva R, Caugant DA, Eribe ERK, et al. Bacterial diversity in aortic aneurysms determined by 16S ribosomal RNA gene analysis. J Vasc Surg. 2006;44:1055–60.

  11. Johnston KW. Multicenter prospective study of nonruptured abdominal aortic aneurysm. Part II. Variables predicting morbidity and mortality. J Vasc Surg. 1989;9:437–47.

  12. Berger P, Vaartjes I, Moll FL, De Borst GJ, Blankensteijn JD, Bots ML. Cumulative incidence of graft infection after primary prosthetic aortic reconstruction in the endovascular era. Eur J Vasc Endovasc Surg. 2015;49:581–5.

  13. Coselli JS, Spiliotopoulos K, Preventza O, de la Cruz KI, Amarasekara H, Green SY. Open aortic surgery after thoracic endovascular aortic repair. Gen Thorac Cardiovasc Surg. 2016;64:441–9.

  14. Chalmers N, Eadington DW, Gandanhamo D, Gillespie IN, Ruckley CV. Case report: infected false aneurysm at the site of an iliac stent. Br J Radiol. 1993;66:946–8.

  15. Mandegaran R, Tang CSW, Pereira EAC, Zavareh A. Spondylodiscitis following endovascular abdominal aortic aneurysm repair: imaging perspectives from a single centre’s experience. Skeletal Radiol. 2018;47:1357–69.

  16. Smeds MR, Duncan AA, Harlander-Locke MP, et al. Treatment and outcomes of aortic endograft infection. J Vasc Surg. 2016;63:332–40.

  17. Cernohorsky P, Reijnen MMPJ, Tielliu IFJ, van Sterkenburg SMM, van den Dungen JJAM, Zeebregts CJ. The relevance of aortic endograft prosthetic infection. J Vasc Surg. 2011;54:327–33.

  18. Vogel TR, Symons R, Flum DR. The incidence and factors associated with graft infection after aortic aneurysm repair. J Vasc Surg. 2008;47:264–9.

  19. LeMaire SA, Coselli JS. Options for managing infected ascending aortic grafts. J Thorac Cardiovasc Surg. 2007;134:839–43.

  20. Faccenna F, Alunno A, Castiglione A, Carnevalini M, Venosi S, Gossetti B. Large aortic pseudoaneurysm and subsequent spondylodiscitis as a complication of endovascular treatment of iliac arteries. Thorac Cardiovasc Surg. 2013;61:606–9.

  21. von der Höh NH, Pieroh P, Henkelmann J, et al. Spondylodiscitis due to transmitted mycotic aortic aneurysm or infected grafts after endovascular aortic aneurysm repair (EVAR): a retrospective single-centre experience with short-term outcomes. Eur Spine J. 2020. https://doi.org/10.1007/s00586-020-06586-2.

  22. Antonello RM, D’Oria M, Cavallaro M, et al. Management of abdominal aortic prosthetic graft and endograft infections. A multidisciplinary update. J Infect Chemother. 2019;25:669–80.

  23. Back RM. Graft infections. In: Sidawy NA, Perler AB, editors. Rutherford’s Vasc Surg Endovasc Ther. 9th ed. Philadelphia: Elsevier; 2019. p. 588–602.

  24. Lin T-W, Kan C-D. Infected aortic aneurysms. In: Kirali K, editor. Aortic aneuryms. Rijeka, Croatia: InTech; 2017. p. 143–69.

  25. Kuo CC, Wu V, Tsai CW, Chou NK, Wang SS, Hsueh PR. Fatal bacteremic mycotic aneurysm complicated by acute renal failure caused by daptomycin-nonsusceptible, vancomycin-intermediate, and methicillin-resistant Staphylococcus aureus. Clin Infect Dis. 2008;47:859–60.

  26. Hsu RB, Tsay YG, Wang SS, Chu SH. Surgical treatment for primary infected aneurysm of the descending thoracic aorta, abdominal aorta, and iliac arteries. J Vasc Surg. 2002;36:746–50.

  27. Choudhary SK, Bhan A, Talwar S, Goyal M, Sharma S, Venugopal P. Tubercular pseudoaneurysms of aorta. Ann Thorac Surg. 2001;72:1239–44.

  28. Canaud L, Marzelle J, Bassinet L, Carrié AS, Desgranges P, Becquemin JP. Tuberculous aneurysms of the abdominal aorta. J Vasc Surg. 2008;48:1012–6.

  29. Long R, Guzman R, Greenberg H, Safneck J, Hershfield E. Tuberculous mycotic aneurysm of the aorta: review of published medical and surgical experience. Chest. 1999;115:522–31.

  30. Seelig MH, Oldenburg WA, Klingler PJ, Blute ML, Pairolero PC. Mycotic vascular infections of large arteries with Mycobacterium bovis after intravesical bacillus Calmette-Guerin therapy: case report. J Vasc Surg. 1999;29:377–81.

  31. Harding GEJ, Lawlor DK. Ruptured mycotic abdominal aortic aneurysm secondary to Mycobacterium bovis after intravesical treatment with bacillus Calmette-Guérin. J Vasc Surg. 2007;46:131–4.

  32. Carrel T, Schmidli J. Management of vascular graft and endoprosthetic infection of the thoracic and thoraco-abdominal aorta. Multimed Man Cardiothorac Surg. 2011. https://doi.org/10.1510/mmcts.2010.004705.

  33. Claeys KC, Heil EL, Pogue JM, Lephart PR, Johnson JK. The Verigene dilemma: gram-negative polymicrobial bloodstream infections and clinical decision making. Diagn Microbiol Infect Dis. 2018;91:144–6.

  34. Arnaoutoglou E, Kouvelos G, Papa N, et al. Prospective evaluation of post-implantation inflammatory response after EVAR for AAA: Influence on patients’ 30 day outcome. Eur J Vasc Endovasc Surg. 2015;49:175–83.

  35. Ishizaka N, Sohmiya K, Miyamura M, et al. Infected aortic aneurysm and inflammatory aortic aneurysm-in search of an optimal differential diagnosis. J Cardiol. 2012;59:123–31.

  36. Kim Y-W. Infected aneurysm: current management. Ann Vasc Dis.2010;3:7–15.

  37. Khaja MS, Sildiroglu O, Hagspiel K, Rehm PK, Cherry KJ, Turba UC. Prosthetic vascular graft infection imaging. Clin Imaging. 2013;37:239–44.

  38. Pennell RC, Hollier LH, Lie JT, et al. Inflammatory abdominal aortic aneurysms: a thirty-year review. J Vasc Surg. 1985;2:859–69.

  39. Walsh DW, Ho VB, Haggerty MF. Mycotic aneurysm of the aorta: MRI and MRA features. J Magn Reson Imaging. 1997;7:312–5.

  40. Fukuchi K, Ishida Y, Higashi M, et al. Detection of aortic graft infection by fluorodeoxyglucose positron emission tomography: comparison with computed tomographic findings. J Vasc Surg. 2005;42:919–25.

  41. Lyons OTA, Baguneid M, Barwick TD, 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;52:758–63.

  42. Lin CH, Hsu RB. Primary infected aortic aneurysm: clinical presentation, pathogen, and outcome. Acta Cardiol Sin. 2014;30:514–21.

  43. Kan CD, Lee HL, Yang YJ. Outcome after endovascular stent graft treatment for mycotic aortic aneurysm: a systematic review. J Vasc Surg. 2007;46:906–12.

  44. Vogt PR, Brunner-La Rocca HP, Carrel T, et al. Cryopreserved arterial allografts in the treatment of major vascular infection: a comparison with conventional surgical techniques. J Thorac Cardiovasc Surg. 1998;116:965–72.

  45. Carrel T, Englberger L, Schmidli J. How to treat aortic graft infection? With a special emphasis on xeno-pericardial aortic tube grafts. Gen Thorac Cardiovasc Surg. 2019;67:44–52.

  46. Khaladj N, Pichlmaier U, Stachmann A, et al. Cryopreserved human allografts (homografts) for the management of graft infections in the ascending aortic position extending to the arch. Eur J Cardiothorac Surg. 2013;43:1170–5.

  47. Carrel TP, Schoenhoff FS, Schmidli J, Stalder M, Eckstein FS, Englberger L. Deleterious outcome of No-React-treated stentless valved conduits after aortic root replacement: Why were Warnings ignored? J Thorac Cardiovasc Surg. 2008;136:52–7.

  48. Heubner L, Schneider U, Giebels C, Karliova I, Raddatz A, Schäfers HJ. Early and long-term outcomes for patients undergoing reoperative aortic root replacement. Eur J Cardiothorac Surg. 2019;55:232–7.

  49. Guenther SPW, Reichelt A, Peterss S, et al. Root replacement for graft infection using an all-biologic xenopericardial conduit. J Heart Valve Dis. 2016;25:440–7.

  50. Kieffer E, Petitjean C, Richard T, Godet G, Dhobb M, Ruotolo C. Exclusion-bypass for aneurysms of the descending thoracic and thoracoabdominal aorta. Ann Vasc Surg. 1986;1:182–95.

  51. Bisdas T, Bredt M, Pichlmaier M, et al. Eight-year experience with cryopreserved arterial homografts for the in situ reconstruction of abdominal aortic infections. J Vasc Surg. 2010;52:323–30.

  52. Clagett GP, Valentine RJ, Hagino RT, et al. Autogenous aortoiliac/femoral reconstruction from superficial femoral-popliteal veins: feasibility and durability. J Vasc Surg. 1997;25:255–66.

  53. Oderich GS, Bower TC, Hofer J, et al. In situ rifampin-soaked grafts with omental coverage and antibiotic suppression are durable with low reinfection rates in patients with aortic graft enteric erosion or fistula. J Vasc Surg. 2011;53:99–106.

  54. Bandyk DF, Novotney ML, Johnson BL, Back MR, Roth SR. Use of rifampin-soaked gelatin-sealed polyester grafts for in situ treatment of primary aortic and vascular prosthetic infections. J Surg Res. 2001;95:44–9.

  55. Harlander-Locke MP, Harmon LK, Lawrence PF, et al. The use of cryopreserved aortoiliac allograft for aortic reconstruction in the United States. J Vasc Surg. 2014;59:669–74.

  56. Brown KE, Heyer K, Rodriguez H, Eskandari MK, Pearce WH, Morasch MD. Arterial reconstruction with cryopreserved human allografts in the setting of infection: A single-center experience with midterm follow-up. J Vasc Surg. 2009;49:660–6.

  57. Kreibich M, Siepe M, Morlock J, et al. Surgical treatment of native and prosthetic aortic infection with xenopericardial tube grafts. Ann Thorac Surg. 2018;106:498–504.

  58. Reilly LM, Altman H, Lusby RJ, Kersh RA, Ehrenfeld WK, Stoney RJ. Late results following surgical management of vascular graft infection. J Vasc Surg. 1984;1:36–44.

  59. Kan CD, Lee HL, Luo CY, Yang YJ. The efficacy of aortic stent grafts in the management of mycotic abdominal aortic aneurysm-institute case management with systemic literature comparison. Ann Vasc Surg. 2010;24:433–40.

  60. Sedivy P, Spacek M, El Samman K, et al. Endovascular treatment of infected aortic aneurysms. Eur J Vasc Endovasc Surg. 2012;44:385–94.

  61. Sorelius K, Mani K, Bjorck M, et al. Endovascular treatment of mycotic aortic aneurysms a European multicenter study. Circulation. 2014;130:2136–42.

  62. Umminger J, Krueger H, Beckmann E, et al. Management of early graft infections in the ascending aorta and aortic arch: A comparison between graft replacement and graft preservation techniques. Eur J Cardiothorac Surg. 2016;50:660–7.

  63. Idhrees AM, Jacob A, Velayudhan BV. An aorto - Oesophageal fistula following endograft: sealing of fistulae with omentum and replacement of the aorta. Interact Cardiovasc Thorac Surg. 2018;26:516–8.

  64. Nakajima N, Masuda M, Ichinose M, Ando M. A new method for the treatment of graft infection in the thoracic aorta: In situ preservation. Ann Thorac Surg. 1999;67:1994–6.

  65. Coselli JS, Crawford ES, Williams TW, et al. Treatment of postoperative infection of ascending aorta and transverse aortic arch, including use of viable omentum and muscle flaps. Ann Thorac Surg. 1990;50:868–81.

  66. Yamashiro S, Arakaki R, Kise Y, Inafuku H, Kuniyoshi Y. Potential role of omental wrapping to prevent infection after treatment for infectious thoracic aortic aneurysms. Eur J Cardiothorac Surg. 2013;43:1177–82.

Download references

Acknowledgements

We wish to thank Dr. V.V. Bashi and Dr. A. Mohammed Idhrees at the Institute of Cardiac & Advanced Aortic Diseases, Chennai, India, for sharing the intra-operative photographs.

Funding

None.

Author information

Authors and Affiliations

  1. Department of Cardiothoracic Surgery, G.Kuppuswamy Naidu Memorial Hospital, Coimbatore, India

    Chandrasekar Padmanabhan & Aayush Poddar

Authors
  1. Chandrasekar Padmanabhan
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Aayush Poddar
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Chandrasekar Padmanabhan.

Ethics declarations

Ethics approval

Not applicable.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Padmanabhan, C., Poddar, A. Infections of the aorta. Indian J Thorac Cardiovasc Surg 38 (Suppl 1), 101–114 (2022). https://doi.org/10.1007/s12055-021-01173-6

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12055-021-01173-6

Keywords

Search

Navigation