Aortic endograft infection is a rare but disastrous complication after fenestrated endovascular aortic aneurysm repair (FEVAR). Only 3 cases treated operatively by endograft explantation are published (1., 2., 3.). There is no international consensus regarding the optimal management of the infected aorta. Biological grafts have showed excellent short-term freedom from infection and reintervention (4.). The case of a patient with infected FEVAR, treated operatively by explantation of the endograft and replacement of the aorta by an in-situ xenopericardial tube graft combined with biosynthetic graft, is presented.

Case report The patient in question is a 71 year old man with comorbidities of active smoking, history of coronary artery disease, cardiac insufficiency with an ejection fraction of 20-25%, pace maker implantation, and erosive arthritis. An asymptomatic juxtarenal abdominal aortic aneurysm (AAA) with a diameter of 7 cm and a right internal iliac aneurysm (RIIA) of 6 cm were treated with a fenestrated endograft consisting covered stents to both renal arteries and a scallop to the superior mesenteric artery combined with a bifurcated endograft to the iliac arteries. The embolisazion of the RIIA was performed. 34 months after the operation the patient suffered from Staphylococcus Aureus septicemia with abdominal pain, fever and hypersedimentation. Intravenous antibiotic treatment was initiated. AAA sack growed rapidly (1 cm in 5 days) with oedema around the aortic wall. The embolized RIIA sack was also grown with liquid content. Ultrasound-guided microbiological samples were collected from AAA sack and Staphylococcus Aureus was found. After 2 weeks of antibiotic treatment and patient informed consent the operation was performed, despite major risk of operative mortality.

The left axillary artery was prepared for balloon occlusion of the thoracoabdominal aorta. The RIIA sack with an abscess and embolization material was completely removed. The infrarenal AAA sack with an abscess was resected and the whole infrarenal aorta was removed circumferentially. The dilated infrarenal aortic neck was saved for proximal anasthomosis. The aortic occlusion balloon failed and supraceliac aortic clamping was needed. Both renal covered stents were removed from inside the aortic graft and the aortic endograft was removed with an extraction device made from 20 ml syringe. The iliac branches were also removed. The aortic clamp was moved infrarenally. The retroperitoneal space was flushed with saline and antibiotics. A 27 mm biological tube graft was made from a xenopericardial patch (Edwards lifesciences Bovine Pericardial Patch), combined with iliac branches made from 8mm biosynthetic graft (LeMaitre Omniflow II Vascular Prosthesis). The graft was sutured proximally to the infrarenal aortic neck and distally to the right external iliac and left common iliac arteries. After the graft placement the occlusion of the left renal artery was noticed and an 8 mm bypass graft with Omniflow II prosthesis was sutured between the aortic tube graft and the left renal artery. The omental flap was sutured over the grafts. (Image 1.) Visceral and right renal ischemic time was 15 minutes. Left renal ischemia was unfortunately longer, about 2 hours. Operation time was 675 minutes. Intraoperative microbiological samples verified Stafylococcus Aureus graft infection. Antibiotics were given postoperatively. Creatinine level increased to 300 umol/l showing an acute kidney injury but no need for dialysis. After 14 days post-operatively the patient was transferred to another hospital for rehabilitation. 1 month after the surgery the patient was rehospitalized with increased inflammatory markers. Abdominal computed tomography (CT) scan demonstrated a fluid collection surrounding the aortic graft. However, percutaneous microbiological samples including bacterial polymerase chain reaction (PCR) were negative and the fluid was serous. Antibiotic treatment continued 4 months after the surgery. The patient recovered to normal activity. Kidney function normalized. Follow-up CT scan 4 and 10 months after the surgery showed no signs of infection nor complications. (Image 2) The graft placement was good and the graft and renal arteries were patent. The patient had no symptoms of infection and the inflammatory markers were normal. Follow-up will be continued.

Aortic endograft infection after FEVAR can be successfully managed with graft explantation, radical revision of all the infected tissue, in situ aortic replacement with xenopericardial and biosynthetic grafts and effective perioperative antibiotic therapy. However, long-term follow-up is needed to establish the patency and infection resistance of the grafts.

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