Current Evidence on Management of Aortic Stent-graft Infection: A Systematic Review and Meta-Analysis

Background: Aortic stent-graft infection (SGI) is rare but remains one of the most challenging and threatening complications. This systematic review aimed to identify the clinical features, treatment, and outcomes of endograft infection after abdominal endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR). Methods: A systematic literature review of all published literature from January 1991 to September 2016 on SGI was performed under the instruction of Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Aorta, aneurysm, endovascular, stent-graft, endograft and infection were the keywords used in our comprehensive search in PubMed and MEDLINE databases. Data analysis was performed using SPSS, V 22.0. Results: A total of 185 potential relevant articles were identified, but only 11 studies with 402 patients met the inclusion criteria. Majority of the patients were male (308/402, 77%), with a mean age ranging from 65 to 73 years. Most of the endografts were implanted for EVAR (351/402, 87%), while the other 51 (13%) endografts were infected following TEVAR. Among the 402 patients, 39 (9.7%) patients presented with aortic rupture. Ninety-two of 380 (24.2%) patients with available data had aortoenteric fistula (AEF). Sixty-nine patients (17%) died in hospital or within 30 days after operation. One hundred fourteen patients (28%) died during follow-up. The most commonly used stent grafts were Zenith (Cook Inc, Bloomington, IN) (22%) and Excluder (W.L. Gore, Flagstaff, AZ) (20%). Of the 402 patients in this series, 108 patients (27%) had negative culture, and multiple microorganisms were identified in 103 patients (26%). The most frequently isolated microorganisms were Staphylcoccus species (30.1%), Streptococcus (14.8%), and fungus (9.2%). Forty-two patients (42/401, 10%) received conservative treatment, whereas 359 (90%) patients underwent surgical treatment, including stent graft removal with in situ reconstruction or extra-anatomical bypass, and secondary endovascular procedure. Patients in the surgical group had a higher survival rate compared with conservative group (58% vs. 33%, P = 0.002). The survival rate was higher in the patients with infected EVAR than TEVAR (58% vs. 27%, P = 0.000). Patient with AEF had a worse prognosis (survival rate 72% vs. 33%, P = 0.002). Conclusions: Current evidence suggests that surgical treatment is a better option compared with conservative management in selected patients with aortic endograft infection. The outcome was worse in patients with infected TEVAR and AEF.