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1. In-situ bypass is associated with superior infection-free survival compared with extra-anatomic bypass for the management of secondary aortic graft infections without enteric involvement

Author

Janko, Matthew R., Hubbard, Grant, Back, Martin, Shah, Samir K., Pomozi, Eniko, Szeberin, Zoltan, DeMartino, Randall, Wang, Linda J., Crofts, Sarah, Belkin, Michael, Davila, Victor J., Lemmon, Gary W., Wang, Shihuan K., Czerny, Martin, Kreibich, Maximilian, Humphries, Misty D., Shutze, William, Joh, Jin Hyun, Cho, Sungsin, Behrendt, Christian-Alexander, Setacci, Carlo, Hacker, Robert, I, Sobreira, Marcone Lima, Yoshida, Winston Bonetti, D'Oria, Mario, Lepidi, Sandro, Chiesa, Roberto, Kahlberg, Andrea, Go, Michael R., Rizzo, Anthony N., Black, James H., Magee, Gregory A., Elsayed, Ramsey, Baril, Donald T., Beck, Adam W., McFarland, Graeme E., Gavali, Hamid, Wanhainen, Anders, Kashyap, Vikram S., Stoecker, Jordan B., Wang, Grace J., Zhou, Wei, Fujimura, Naoki, Obara, Hideaki, Wishy, Andrew M., Bose, Saideep, Smeds, Matthew, Liang, Patric, Schermerhorn, Marc, Conrad, Mark F., Hsu, Jeffrey H., Patel, Rhusheet, Lee, Jason T., Liapis, Christos D., Moulakakis, Konstantinos G., Farber, Mark A., Motta, Fernando, Ricco, Jean-Baptiste, Bath, Jonathan, Coselli, Joseph S., Aziz, Faisal, Coleman, Dawn M., Davis, Frank M., Fatima, Javairiah, Irshad, Ali, Shalhub, Sherene, Kakkos, Stavros, Zhang, Qianzi, Lawrence, Peter F., Woo, Karen, Chung, Jayer, Janko, Matthew R., Hubbard, Grant, Back, Martin, Shah, Samir K., Pomozi, Eniko, Szeberin, Zoltan, DeMartino, Randall, Wang, Linda J., Crofts, Sarah, Belkin, Michael, Davila, Victor J., Lemmon, Gary W., Wang, Shihuan K., Czerny, Martin, Kreibich, Maximilian, Humphries, Misty D., Shutze, William, Joh, Jin Hyun, Cho, Sungsin, Behrendt, Christian-Alexander, Setacci, Carlo, Hacker, Robert, I, Sobreira, Marcone Lima, Yoshida, Winston Bonetti, D'Oria, Mario, Lepidi, Sandro, Chiesa, Roberto, Kahlberg, Andrea, Go, Michael R., Rizzo, Anthony N., Black, James H., Magee, Gregory A., Elsayed, Ramsey, Baril, Donald T., Beck, Adam W., McFarland, Graeme E., Gavali, Hamid, Wanhainen, Anders, Kashyap, Vikram S., Stoecker, Jordan B., Wang, Grace J., Zhou, Wei, Fujimura, Naoki, Obara, Hideaki, Wishy, Andrew M., Bose, Saideep, Smeds, Matthew, Liang, Patric, Schermerhorn, Marc, Conrad, Mark F., Hsu, Jeffrey H., Patel, Rhusheet, Lee, Jason T., Liapis, Christos D., Moulakakis, Konstantinos G., Farber, Mark A., Motta, Fernando, Ricco, Jean-Baptiste, Bath, Jonathan, Coselli, Joseph S., Aziz, Faisal, Coleman, Dawn M., Davis, Frank M., Fatima, Javairiah, Irshad, Ali, Shalhub, Sherene, Kakkos, Stavros, Zhang, Qianzi, Lawrence, Peter F., Woo, Karen, and Chung, Jayer

Abstract

Objective: The optimal revascularization modality following complete resection of aortic graft infection (AGI) without enteric involvement remains unclear. The purpose of this investigation is to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients undergoing complete excision of AGI. Methods: A retrospective, multi-institutional study of AGI from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and perioperative variables were recorded. The primary outcome was infection-free survival. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariable analyses were performed. Results: A total of 241 patients at 34 institutions from seven countries presented with AGI during the study period (median age, 68 years; 75% male). The initial aortic procedures that resulted in AGI were 172 surgical grafts (71%), 66 endografts (27%), and three unknown (2%). Of the patients, 172 (71%) underwent complete excision of infected aortic graft material followed by in situ (in-line) bypass (ISB), including antibiotic-treated prosthetic graft (35%), autogenous femoral vein (neo-aortoiliac surgery) (24%), and cryopreserved allograft (41%). Sixty-nine patients (29%) underwent extra-anatomic bypass (EAB). Overall median Kaplan-Meier estimated survival was 5.8 years. Perioperative mortality was 16%. When stratified by ISB vs EAB, there was a significant difference in Kaplan-Meier estimated infection-free survival (2910 days; interquartile range, 391-3771 days vs 180 days; interquartile range, 27-3750 days; P <.001). There were otherwise no significant differences in presentation, comorbidities, or perioperative variables. Multivariable Cox regression showed lower infection-free survival among patients with EAB (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.6-3.6; P <.001), polymicrobial infection (HR, 2.2; 95% CI, 1.4-3.5; P = .001)

Published
2022
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2. Contemporary Outcomes After Partial Resection of Infected Aortic Grafts

Author

Janko, Matthew, Hubbard, Grant, Woo, Karen, Kashyap, Vikram S, Mitchell, Megan, Murugesan, Arun, Chen, Lin, Gardner, Rachel, Baril, Donald, Hacker, Robert I, Szeberin, Zoltan, ElSayed, Ramsey, Magee, Gregory A, Motta, Fernando, Zhou, Wei, Lemmon, Gary, Coleman, Dawn, Behrendt, Christian-Alexander, Aziz, Faisal, Black, James H, Tran, Kimberly, Dao, Allen, Shutze, William, Garrett, H Edward, De Caridi, Giovanni, Patel, Rhusheet, Liapis, Christos D, Geroulakos, George, Kakisis, John, Moulakakis, Konstantinos, Kakkos, Starvos K, Obara, Hideaki, Wang, Grace, Stoecker, Jordan, Rhéaume, Pascal, Davila, Victor, Ravin, Reid, DeMartino, Randall, Milner, Ross, Shalhub, Sherene, Jim, Jeffrey, Lee, Jason, Dubuis, Celine, Ricco, Jean-Baptiste, Coselli, Joseph, Lemaire, Scott, Fatima, Javairiah, Sanford, Jennifer, Yoshida, Winston, Schermerhorn, Marc L, Menard, Matthew, Belkin, Michael, Blackwood, Stuart, Conrad, Mark, Wang, Linda, Crofts, Sara, Nixon, Thomas, Wu, Timothy, Chiesa, Roberto, Bose, Saideep, Turner, Jason, Moore, Ryan, Smith, Justin, Irshad, Ali, Hsu, Jeffrey, Czerny, Martin, Cullen, Jonathan, Kahlberg, Andrea, Setacci, Carlo, Joh, Jin Hyun, Senneville, Eric, Garrido, Pedro, Sarac, Timur P, Rizzo, Anthony, Go, Michael R, Björck, Martin, Gavali, Hamid, Wanhainen, Anders, D'Oria, Mario, Lepidi, Sandro, Mastrorilli, Davide, Veraldi, Gianfranco, Piazza, Michele, Squizzato, Francesco, Beck, Adam, St John, Rebecca, Wishy, Andrew, Humphries, Misty, Shah, Samir K, Back, Martin, Chung, Jayer, Lawrence, Peter F, Bath, Jonathan, Smeds, Matthew R, Janko, Matthew, Hubbard, Grant, Woo, Karen, Kashyap, Vikram S, Mitchell, Megan, Murugesan, Arun, Chen, Lin, Gardner, Rachel, Baril, Donald, Hacker, Robert I, Szeberin, Zoltan, ElSayed, Ramsey, Magee, Gregory A, Motta, Fernando, Zhou, Wei, Lemmon, Gary, Coleman, Dawn, Behrendt, Christian-Alexander, Aziz, Faisal, Black, James H, Tran, Kimberly, Dao, Allen, Shutze, William, Garrett, H Edward, De Caridi, Giovanni, Patel, Rhusheet, Liapis, Christos D, Geroulakos, George, Kakisis, John, Moulakakis, Konstantinos, Kakkos, Starvos K, Obara, Hideaki, Wang, Grace, Stoecker, Jordan, Rhéaume, Pascal, Davila, Victor, Ravin, Reid, DeMartino, Randall, Milner, Ross, Shalhub, Sherene, Jim, Jeffrey, Lee, Jason, Dubuis, Celine, Ricco, Jean-Baptiste, Coselli, Joseph, Lemaire, Scott, Fatima, Javairiah, Sanford, Jennifer, Yoshida, Winston, Schermerhorn, Marc L, Menard, Matthew, Belkin, Michael, Blackwood, Stuart, Conrad, Mark, Wang, Linda, Crofts, Sara, Nixon, Thomas, Wu, Timothy, Chiesa, Roberto, Bose, Saideep, Turner, Jason, Moore, Ryan, Smith, Justin, Irshad, Ali, Hsu, Jeffrey, Czerny, Martin, Cullen, Jonathan, Kahlberg, Andrea, Setacci, Carlo, Joh, Jin Hyun, Senneville, Eric, Garrido, Pedro, Sarac, Timur P, Rizzo, Anthony, Go, Michael R, Björck, Martin, Gavali, Hamid, Wanhainen, Anders, D'Oria, Mario, Lepidi, Sandro, Mastrorilli, Davide, Veraldi, Gianfranco, Piazza, Michele, Squizzato, Francesco, Beck, Adam, St John, Rebecca, Wishy, Andrew, Humphries, Misty, Shah, Samir K, Back, Martin, Chung, Jayer, Lawrence, Peter F, Bath, Jonathan, and Smeds, Matthew R

Abstract

INTRODUCTION: Aortic graft infection remains a considerable clinical challenge, and it is unclear which variables are associated with adverse outcomes among patients undergoing partial resection. METHODS: A retrospective, multi-institutional study of patients who underwent partial resection of infected aortic grafts from 2002 to 2014 was performed using a standard database. Baseline demographics, comorbidities, operative, and postoperative variables were recorded. The primary outcome was mortality. Descriptive statistics, Kaplan-Meier (KM) survival analysis, and Cox regression analysis were performed. RESULTS: One hundred fourteen patients at 22 medical centers in 6 countries underwent partial resection of an infected aortic graft. Seventy percent were men with median age 70 years. Ninety-seven percent had a history of open aortic bypass graft: 88 (77%) patients had infected aortobifemoral bypass, 18 (16%) had infected aortobiiliac bypass, and 1 (0.8%) had an infected thoracic graft. Infection was diagnosed at a median 4.3 years post-implant. All patients underwent partial resection followed by either extra-anatomic (47%) or in situ (53%) vascular reconstruction. Median follow-up period was 17 months (IQR 1, 50 months). Thirty-day mortality was 17.5%. The KM-estimated median survival from time of partial resection was 3.6 years. There was no significant survival difference between those undergoing in situ reconstruction or extra-anatomic bypass (P = 0.6). During follow up, 72% of repairs remained patent and 11% of patients underwent major amputation. On univariate Cox regression analysis, Candida infection was associated with increased risk of mortality (HR 2.4; P = 0.01) as well as aortoenteric fistula (HR 1.9, P = 0.03). Resection of a single graft limb only to resection of abdominal (graft main body) infection was associated with decreased risk of mortality (HR 0.57, P = 0.04), as well as those with American Society of Anesthesiologists classification less than 3

Published
2021
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3. In situ bypass and extra-anatomic bypass procedures result in similar survival in patients with secondary aortoenteric fistulas

Author

Janko, Matthew R., Woo, Karen, Hacker, Robert I., Baril, Donald, Bath, Jonathan, Smeds, Matthew R., Kashyap, Vikram S., Szeberin, Zoltan, Magee, Gregory A., Elsayed, Ramsey, Wishy, Andrew, St John, Rebecca, Beck, Adam, Farber, Mark, Motta, Fernando, Zhou, Wei, Lemmon, Gary, Coleman, Dawn, Behrendt, Christian-Alexander, Aziz, Faisal, Black, James, Shutze, William, Garrett, H. Edward, Jr., De Caridi, Giovanni, Liapis, Christos D., Geroulakos, George, Kakisis, John, Moulakakis, Konstantinos, Kakkos, Stavros K., Obara, Hideaki, Wang, Grace, Rheaume, Pascal, Davila, Victor, Ravin, Reid, DeMartino, Randall, Milner, Ross, Shalhub, Sherene, Jim, Jeffrey, Lee, Jason, Dubuis, Celine, Ricco, Jean-Baptiste, Coselli, Joseph, Lemaire, Scott, Fatima, Javairiah, Sanford, Jennifer, Yoshida, Winston, Schermerhorn, Marc L., Menard, Matthew, Belkin, Michael, Blackwood, Stuart, Conrad, Mark, Wang, Linda, Crofts, Sara, Nixon, Thomas, Wu, Timothy, Chiesa, Roberto, Bose, Saideep, Turner, Jason, Moore, Ryan, Smith, Justin, Ciocca, Rocco, Hsu, Jeffrey, Czerny, Martin, Cullen, Jonathan, Kahlberg, Andrea, Setacci, Carlo, Joh, Jin Hyun, Senneville, Eric, Garrido, Pedro, Sarac, Timur P., Rizzo, Anthony, Go, Michael R., Björck, Martin, Gavali, Hamid, Wanhainen, Anders, Lawrence, Peter F., Janko, Matthew R., Woo, Karen, Hacker, Robert I., Baril, Donald, Bath, Jonathan, Smeds, Matthew R., Kashyap, Vikram S., Szeberin, Zoltan, Magee, Gregory A., Elsayed, Ramsey, Wishy, Andrew, St John, Rebecca, Beck, Adam, Farber, Mark, Motta, Fernando, Zhou, Wei, Lemmon, Gary, Coleman, Dawn, Behrendt, Christian-Alexander, Aziz, Faisal, Black, James, Shutze, William, Garrett, H. Edward, Jr., De Caridi, Giovanni, Liapis, Christos D., Geroulakos, George, Kakisis, John, Moulakakis, Konstantinos, Kakkos, Stavros K., Obara, Hideaki, Wang, Grace, Rheaume, Pascal, Davila, Victor, Ravin, Reid, DeMartino, Randall, Milner, Ross, Shalhub, Sherene, Jim, Jeffrey, Lee, Jason, Dubuis, Celine, Ricco, Jean-Baptiste, Coselli, Joseph, Lemaire, Scott, Fatima, Javairiah, Sanford, Jennifer, Yoshida, Winston, Schermerhorn, Marc L., Menard, Matthew, Belkin, Michael, Blackwood, Stuart, Conrad, Mark, Wang, Linda, Crofts, Sara, Nixon, Thomas, Wu, Timothy, Chiesa, Roberto, Bose, Saideep, Turner, Jason, Moore, Ryan, Smith, Justin, Ciocca, Rocco, Hsu, Jeffrey, Czerny, Martin, Cullen, Jonathan, Kahlberg, Andrea, Setacci, Carlo, Joh, Jin Hyun, Senneville, Eric, Garrido, Pedro, Sarac, Timur P., Rizzo, Anthony, Go, Michael R., Björck, Martin, Gavali, Hamid, Wanhainen, Anders, and Lawrence, Peter F.

Abstract

Objective: The optimal revascularization modality in secondary aortoenteric fistula (SAEF) remains unclear in the literature. The purpose of this investigation was to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients with SAEF. Methods: A retrospective, multi-institutional study of SAEF from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and operative and postoperative variables were recorded. The primary outcome was long-term mortality. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariate analyses were performed. Results: During the study period, 182 patients at 34 institutions from 11 countries presented with SAEF (median age, 72 years; 79% male). The initial aortic procedures that resulted in SAEF were 138 surgical grafts (76%) and 42 endografts (23%), with 2 unknown; 102 of the SAEFs (56%) underwent complete excision of infected aortic graft material, followed by in situ (in-line) bypass (ISB), including antibiotic-soaked prosthetic graft (53), autogenous femoral vein (neoaortoiliac surgery; 17), cryopreserved allograft (28), and untreated prosthetic grafts (4). There were 80 patients (44%) who underwent extra-anatomic bypass (EAB) with infected graft excision. Overall median Kaplan-Meier estimated survival was 319 days (interquartile range, 20-2410 days). Stratified by EAB vs ISB, there was no significant difference in Kaplan-Meier estimated survival (P = .82). In comparing EAB vs ISB, EAB patients were older (74 vs 70 years; P = .01), had less operative hemorrhage (1200 mL vs 2000 mL; P = .04), were more likely to initiate dialysis within 30 days postoperatively (15% vs 5%; P = .02), and were less likely to experience aorta-related hemorrhage within 30 days postoperatively (3% aortic stump dehiscence vs 11% anastomotic rupture; P = .03). There were otherwise no significant differences in presentation, c

Published
2021
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