Aortic infections represent a rare but life-threatening condition and remains a significant challenge for the aortic surgeon. Reconstruction with in-situ biological grafts, in addition to antimicrobial therapy, is an effective strategy for the management of aortic graft infections. Infections affecting the visceral segment increase the complexity of repair and are associated with increased morbidity and mortality.

We present the management of an infected thoraco-abdominal aneurysm involving the visceral segment with endovascular graft explant and aortic reconstruction with a custom-made composite graft of bovine pericardium and deep veins.

An 80-year-old male presented with back pain on a background of prostate and bladder cancer, renal stones with recurrent urinary tract infections, ischaemic heart disease and Type 2 diabetes mellitus. CT-angiography at presentation demonstrated a mycotic supracoeliac aneurysm, with extension to the visceral segment. He was initially managed with broad spectrum antibiotics and an emergency endovascular repair. Due to the narrow aortic lumen, he required a TEVAR, 2 chimneys (superior mesenteric artery and right renal artery) and a snorkel/Periscope stent graft to the left renal artery. His coeliac trunk was covered in order to provide adequate seal. Post-operatively, he continued to spike temperatures with raised inflammatory markers despite maximal appropriate antimicrobial therapy. Further CT imaging demonstrated a Type 1A endoleak with loss of seal, likely secondary to extension of the infection in the proximal sealing zone. Following multiple discussions at the multidisciplinary aortic infection meeting, decision was made to explant his stent graft and reconstruct the aorta using a biological graft given ongoing uncontrollable sepsis and active endoleak. Six weeks after his initial endovascular procedure, he underwent an explant of all stent grafts and a Type III thoraco-abdominal aortic reconstruction under left heart bypass with a bench-prepared custom-made aortic graft. A long bovine pericardium patch was fashioned into a tube with two branches made from right superficial femoral vein grafts for the superior mesenteric artery and left renal artery. The graft was anastomosed at the descending aorta at T8/9 proximally, with a long bevelled distal anastomosis to include right renal artery ostium. There was extensive debridement of infected tissue and multiple biopsies were taken for microbiology and culture. Post-operatively, he required ultrasound guided drainage of left pleural and left retroperitoneal collections. There was no organism growth from any intra-operative tissue samples however, pre-operative urine samples isolated methicillin resistant Staphylococcus Aureus therefore he was placed on empirical Meropenem, Vancomycin, Anidulafungin. This was converted to oral Ciprofloxacin and Linezolid on discharge. He completed his recommended 12-week course of antibiotic therapy. He had a subsequent readmission with suspected reinfection but was diagnosed with acalculous cholecystitis and managed with antibiotics only. At 6 months follow up, he was clinically well and off all antimicrobial therapy; with normal inflammatory markers and no signs of active infection on PET and CT imaging. He required kissing iliac stents for short distance claudication 18 months after his explant surgery. At latest follow up (28 months post-explant), he has recovered back to his functional baseline and remains well. Latest follow up imaging showed satisfactory appearances of the implanted biological graft with patent branches and no evidence of infection.

To our knowledge, this is the first published case report in the literature of an extensive aortic reconstruction of the mid-descending thoracic aorta to the infra-renal aortic segment, including the visceral segment, with a custom-made in-situ anatomical biological graft for graft infection. From our experience, open surgical management for aortic graft infection, even in complex Type III repairs involving the visceral segment, is effective and feasible in selected patients. Multidisciplinary input with a dedicated aortic infection team and appropriate pre-operative planning is important to improve patient outcomes.