Secondary Infections of Thoracic and Abdominal Aortic Endografts Kamaldeep S. Heyer, MD, Parth Modi, BA, Mark D. Morasch, MD, Jon S. Matsumura, MD, Melina R. Kibbe, MD, William H. Pearce, MD, Scott A. Resnick, MD, and Mark K. Eskandari, MD PURPOSE: To review several cases of stent-graft infection with respective outcomes to identify clinical presentations and responses to treatment options. MATERIALS AND METHODS: The authors performed a single-center retrospective review of all secondary en- dograft infections from January 2000 to June 2007. Infections were identified from an institutional database containing all abdominal and thoracic endovascular aneurysm repairs (EVAR and TEVAR) performed at the treating hospital. RESULTS: From January 2000 to June 2007, 389 EVAR and 105 TEVAR were performed at the treating hospital. Ten endograft infections were identified (five EVAR and five TEVAR). Four infections occurred in grafts placed at outside institutions and six in grafts placed in-house. The in-house prevalence of EVAR and TEVAR infection is 0.26% and 4.77%, respectively. None were placed for a presumed pre-existing mycotic aneurysm. The mean time from the index procedure to the diagnosis of infection was 243.6 days  74.5. Two patients who underwent EVAR presented with a contained rupture, and the remaining eight patients presented with constitutional symptoms and/or abscess formation on imaging studies. Microbiology cultures revealed Propionibacterium species (n  3), Staphylcoccus species (n  3), Streptococcus species (n  2), and Enterobacter cloacae (n  1). All EVAR patients underwent removal of the infected endograft and reconstruction with extraanatomic bypass (n  3) or in situ homograft placement (n  2). During a mean follow-up of more than 1 year, there were no recognized complications or recurrence of infection. Only one of the five TEVAR patients underwent removal and interposition grafting with an antibiotic-impregnated Dacron graft. The remaining four patients were medically managed— one patient survived and was placed in hospice care, two died of mycotic aneurysm rupture, and one died from multiorgan system failure secondary to sepsis. CONCLUSIONS: Graft-related septic complications following EVAR or TEVAR are rare but associated with signif- icant mortality. Several surgical treatment options are available, each potentially equally successful. The effect of prophylactic antibiotic use during subsequent invasive procedures must be solidified. J Vasc Interv Radiol 2009; 20:173–179 Abbreviations: EVAR = endovascular abdominal aortic aneurysm repair, TEVAR = thoracic endovascular aneurysm repair ENDOVASULAR abdominal aortic an- eurysm repair (EVAR) and thoracic en- dovascular aneurysm repair (TEVAR) have become well-accepted alternatives to traditional open surgery because of the diminished perioperative complica- tions (1). Crucial to the long-term suc- cess of endoluminal exclusion is the commitment to lifelong imaging sur- veillance. The vast majority of sec- ondary surveillance is primarily fo- cused on the technical limitations of devices and the assessment of aneu- rysm sac size, endoleaks, migration, limb occlusion, and material fatigue (2). Due to the rarity of secondary endograft infectious complications, scarce clinical data and management are available. The clinical presentation, inci- dence, and management of pros- thetic graft infection after traditional open surgical aortic repair have been more thoroughly studied. The typi- cal clinical manifestation is either fe- vers of unknown origin with abdom- From the Division of Vascular Surgery (K.S.H., P.M., M.D.M., J.S.M., M.R.K., W.H.P., S.A.R., M.K.E.) and Department of Radiology (S.A.R., M.K.E.), North- western University Feinberg School of Medicine, 201 E Huron St, Galter 10-105, Chicago, IL 60611. Re- ceived March 19, 2008; final revision received Octo- ber 23, 2008; accepted October 28, 2008. Address correspondence to M.K.E.; E-mail: meskanda@nmh. org From the 2008 SIR Annual Meeting. M. K. E. serves as a consultant for Guidant, Cordis, Abbott Vascular Devices, Medtronic, Boston Scien- tific, Terumo and W. L. Gore & Associates, Inc. J. M. has been a consultant, paid speaker and has received research support from Abbott Vascular, Inc. and W. L. Gore & Associates. He has been a consultant and received grant/research support from Cook, Cordis and EV3 and has received grant/research support from Bard, Lumen and Medtronic. He does not own stock, patents or have employment with these or other competitors. M. D. M. receives re- search support from W. L. Gore & Associates, Inc., Guidant Corporation, Cook Incorporated, and Medtronic. He receives honoraria for serving as training course director for W. L. Gore & Associates, Inc. and as consultant for King Pharmaceuticals, and Vascular Surgery division support for serving as training course director for Abbott Vascular. © SIR, 2009 DOI: 10.1016/j.jvir.2008.10.032 173