腹主动脉瘤腔内修复术后移植物感染的治疗及预后分析

目的:总结腹主动脉瘤腔内修复术(EVAR)后移植物感染的诊治经验。方法:回顾性总结中山大学附属第一医院血管外科2011年1月至2019年6月诊治的腹主动脉瘤EVAR术后移植物感染的患者资料,并对感染原因、临床表现、再次干预方式及预后进行分析。结果:15例患者均为男性,中位年龄65岁(48~77岁),与首次EVAR的中位间隔时间为7.5个月(21 d^27个月),合并主动脉肠瘘(AEF)6例(40%),细菌培养阳性率47%(7/15)。4例(AEF 2例、无AEF 2例)接受保守治疗。11例(AEF 4例,无AEF 7例)接受手术取出支架,其中9例行腋-双股动脉旁路+主动脉残端闭合,2例行原位腹主动脉重建,其中合并AEF者同时进行了肠瘘修补术。30 d内死亡率为33%(5/15),围术期死亡3例,保守治疗2例且为合并AEF患者。10例存活患者中位随访时间33个月(6~54个月)。2例保守治疗者中长期死亡率为50%(1/2),感染再发率为100%(2/2);8例术后患者仅1例2年后死于脑血管意外,中长期死亡率为13%(1/8),感染再发率为0%(0/8)。患者总体死亡率为47%(7/15),其中合并AEF患者(67%,4/6)30 d内死亡率高于无AEF者(11%,1/11)(P=0.047),而合并AEF(50%,1/2)和无AEF患者(25%,2/8)中长期死亡率及感染再发率无明显差异(P=0.38)。结论:EVAR术后移植物感染死亡率高,而合并AEF患者早期死亡率高。保守治疗往往效果不佳,基于充分的抗感染后的外科治疗是一个有效的干预措施。

Treatment strategies and outcomes of endograft infections following endovascular abdominal aneurysm repair

Objective To summarize the experience of diagnosis and treatment of stent infection after endovascular abdominal aneurysm repair(EVAR).Methods This retrospective analysis of post-EVAR stent infections was conducted at the First Affiliated Hospital,Sun Yat-sen University from January 2011 to June 2019,and the causes,clinical manifestations,reintervention and prognosis of infection were analyzed.Results Fifteen patients were identified,and all were male,with a median age of 65 years(range:48~77 years).The median interval time between onset and EVAR was 7.5 months(range:21 d^27 months).Aortoenteric fistula(AEF)was found in 6 patients(40%).Only 7 patients(47%)were positive of bacterial culture.Four(2 AEF,2 non-AEF)received conservative treatment.Stent removal was performed in 11 patients(4 AEF,7 non-AEF).Among them,9 patients underwent axillary-bilateral femoral artery bypass,2 patients underwent abdominal aorta reconstruction in situ and the patients with AEF underwent intestinal fistula repair at the same time.The 30-day early mortality was 33%(5/15),including 3 cases died in the perioperative period and the other 2 patients complicated with AEF died after conservative treatment.The median follow-up time of 10 survivors was 33 months(range:6~54 months).Among them,2 cases of infection recurred after conservative treatment with a middle and long-term death rate of 50%(1/2)and a recurrence rate of 100%(2/2).In 8 postperative patients,only one died of cerebrovascular accident two years later,whereas no recurrence of infection occurred.The middle and long-term death rate and the recurrence rate of postoperative patients was 13%(1/8)and 0%(0/8),respectively.In total,the overall mortality was 47%(7/15).The early mortality rate of patients with AEF was higher than that of non-AEF67%(4/6)vs 11%(1/11),P=0.047],but there was no significant difference in the long-term mortality and infection recurrence rate50%(1/2)vs 25%(2/8),P=0.38].Conclusions Outcomes of stent infection after EVAR are poor,and AEF is common presentation that portend a significantly worse prognosis.Surgery is an effective treatment based on adequate anti-infective treatment.