Faculty of Medicine, Sorbonne University, Paris, France; Department of Vascular Surgery, Pitié-Salpêtrière University Hospital, Paris, France.
Faculty of Medicine, Sorbonne University, Paris, France; Department of Vascular Surgery, Pitié-Salpêtrière University Hospital, Paris, France.
J Vasc Surg. 2021 Feb;73(2):626-634. doi: 10.1016/j.jvs.2020.05.052.
Primary and secondary thoracic aortic infections are rare but associated with high morbidity and mortality. There is currently no consensus on their optimal treatment. Arterial allografts have been shown to be resistant to bacterial colonization. Complete excision of infected material, especially synthetic grafts, combined with in situ aortic repair is considered the best treatment of abdominal aortic infections. The aim of this study was to assess the management of thoracic and thoracoabdominal aortic infections using arterial allografts.
Between January 2009 and December 2017, all patients with thoracic and thoracoabdominal aortic native or graft infections underwent complete excision of infected material and in situ arterial allografting. The end points were the early mortality and morbidity rates and early and late rates of reinfection, graft degeneration, and graft-related morbidity.
Thirty-five patients with a mean age of 65.6 ± 9.2 years were included. Twenty-one (60%) cases experienced graft infections and 14 (40%) experienced native aortic infections. Eight (22.8%) patients had visceral fistulas: 5 (14.4%) prosthetic-esophageal, 1 (2.8%) prosthetic-bronchial, 1 (2.8%) prosthetic-duodenal, and 1 (2.8%) native aortobronchial. In 12 (34.3%) cases, only the descending thoracic aorta was involved; in 23 (65.7%) cases, the thoracoabdominal aorta was involved. Fifteen (42.8%) patients died during the first month or before discharge: 5 of hemorrhage, 4 of multiorgan failure, 3 of ischemic colitis, 2 of pneumonia, and 1 of anastomotic disruption. Eleven (31.5%) patients required early revision surgery: 6 (17.1%) for nongraft-related hemorrhage, 3 (8.6%) for colectomy, 1 (2.9%) for proximal anastomotic disruption, and 1 (2.9%) for tamponade. One (2.9%) patient who died before discharge experienced paraplegia. One (2.9%) patient experienced stroke. Six (17.1%) patients required postoperative dialysis. Among them, four died before discharge. The mean length of stay in the intensive care unit was 11 ± 10.5 days; the mean length of hospital stay was 32 ± 14 days. During a mean follow-up of 32.3 ± 23.7 months, three allograft-related complications occurred in survivors (15% of late survivors): one proximal and one distal false aneurysm with no evidence of reinfection and one allograft-enteric fistula. The 1-year and 2-year survival rates were 49.3% and 42.5%, respectively.
Although rare, aortic infections are highly challenging. Surgical management includes complete excision of infected tissues or grafts. Allografts offer a promising solution to aortic graft infection because they appear to resist reinfection; however, the grafts must be observed indefinitely because of the risk of late graft complications.
原发性和继发性胸主动脉感染较为罕见，但发病率和死亡率较高。目前对于其最佳治疗方法尚未达成共识。异体血管移植物具有抵抗细菌定植的能力。完全切除感染性物质，尤其是合成移植物，并结合原位主动脉修复，被认为是治疗腹主动脉感染的最佳方法。本研究旨在评估使用动脉同种异体移植物治疗胸主动脉和胸腹主动脉感染的效果。
2009 年 1 月至 2017 年 12 月，所有患有胸主动脉和胸腹主动脉原发性或移植物感染的患者均接受了感染性物质的完全切除和原位动脉同种异体移植物植入。研究终点是早期死亡率和发病率，以及早期和晚期再次感染、移植物退化和移植物相关发病率。
35 例患者的平均年龄为 65.6±9.2 岁。21 例（60%）患者发生移植物感染，14 例（40%）患者发生原发性主动脉感染。8 例（22.8%）患者有内脏瘘：5 例（14.4%）为人工食管瘘，1 例（2.8%）为人工支气管瘘，1 例（2.8%）为人工十二指肠瘘，1 例（2.8%）为原发性主动脉支气管瘘。在 12 例（34.3%）患者中，仅累及降主动脉；23 例（65.7%）患者累及胸腹主动脉。15 例（42.8%）患者在第一个月或出院前死亡：5 例因出血，4 例因多器官功能衰竭，3 例因缺血性结肠炎，2 例因肺炎，1 例因吻合口破裂。11 例（31.5%）患者需要早期修正手术：6 例（17.1%）因非移植物相关出血，3 例（8.6%）因结肠切除术，1 例（2.9%）因近端吻合口破裂，1 例（2.9%）因填塞。1 例（2.9%）在出院前死亡的患者出现截瘫。1 例（2.9%）患者发生中风。6 例（17.1%）患者需要术后透析。其中 4 例在出院前死亡。重症监护病房平均住院时间为 11±10.5 天；平均住院时间为 32±14 天。在平均 32.3±23.7 个月的随访期间，3 例存活患者发生了与移植物相关的并发症（晚期存活者的 15%）：1 例近端和 1 例远端假性动脉瘤，无再次感染证据，1 例移植物-肠瘘。1 年和 2 年的生存率分别为 49.3%和 42.5%。
尽管主动脉感染较为罕见，但仍极具挑战性。外科治疗包括完全切除感染组织或移植物。同种异体移植物为主动脉移植物感染提供了一个有希望的解决方案，因为它们似乎能抵抗再次感染；然而，由于存在晚期移植物并发症的风险，必须对移植物进行无限期观察。
