TEVAR for ruptured aortic infections

Department of Cardiovascular Surgery 1), Radiology 2)

Kobe University Graduate School of Medicine

Department of Radiology, Kobe Redcross Hospital 3)

A. Kitagawa 1), Y. Okita 1) , K. Okada 1), Y. Morimoto 1), M. Matsumori 1), H. Munakata 1), M. Yamaguchi 2), K. Sugimura 2) K. Sugimoto 3)

Background

Ruptured aortic infections caused by aortoesophageal

fistula (AEF) or aortobronchial fistula (ABF) are the life-

threatening diseases.

Objective

We analyzed our results of TEVAR (thoracic

endovascular aortic repair) for ruptured aortic

infections.

2000.1~2008.3

Number: 6 cases (male 3, female 3) Age: 63 ±7 years old (53 - 82 )Follow-up: 1.8 ±2.0 years (7days– 3.4 years)

Etiology: AEF 4ABF 1pyothorax 1

Patients’ Profile

TEVAR for AEF (died on 163 POD)

1) TEVAR 2) 1days after TEVAR

before after

60 year-old, male , ULP in the chronic aortic dissection, with hematemesis

Esophagectomy withcervical esophagostomy,gastrostomy & jejunostomy

3) 14days after TEVAR

sepsis

EAB with removal ofinfected aorta & stent-graft

Case 1.

Abcess formationin the

pseudolumen

MRSA graft infection

Leakage fromthe esophagealfistula

66 year-old, male with acute spondylitis (Streptococcus)TEVAR for AEF (survived)

<endoscopy>

1) before TEVAR 2) after TEVAR 3) Staged surgery day 3: EAB + arch division

Case 2.

aorta resectionesophagectomy

No stent-graft infection

day 8:

53 year-old, male with pyothorax(pseudomonas) broncho fistula after lung surgeryTEVAR for aortic infection (survived)Case 3.

Stent-graft infection(pseudomonas)

Bleeding fromthe distal arch

1) before TEVAR 2) after TEVAR 3) Staged surgery day 3: EAB + arch division

aorta resectionesophagectomy

day 11:

64 year-old, female , post op of esophageal cancerTEVAR for AEF(between the reconstructed gastric roll – aorta)

1) before TEVAR 2) TEVAR

before after

(esophagectomy with cervical esophagostomy)

Case 4.

Pseudoaneurysmat the aorta suture line(repair for the fistel)

Ao

Noinfectio

n

82 year-old, female with massive hemoptysisTEVAR for ABF (survived)

1) before TEVAR 2) after TEVAR

Case 6.

No infection

Bleeding intothe left lung

No. age gender Etiology stent-graft prognosispathogen1 additional procedure

2. Es: esophagostomy, Gs: gastrostomy, Js: jejunostomy

Summaryop time

1 60 M AEF Z stent diedMRSAEsophagectomyEs, Gs, Js 2

120

late mortality(cancer)

4 64 F Z stent none 120

survived5 72 F Z stent drainage 90

survived2 66 M MK stent(nitinol)

staged surgery Streptocoocus160

6 82 F Z stent none 140 None survived

survived3 53 M MK stent staged surgery Pseudomonas106

AEF

pyothorax

AEF

AEF

ABF

Candida

None

(fish bone)

(spondilytis)

Initial success of TEVAR 6 (100 %)

Mortality: 30-day 0 ( 0 %)In-hospital 1 (16.7%)late 1 (16.7%)

(cancer)

Morbidity: stent graft infection 2 (33.4%)Case 1: died (MRSA)Case 3: survived (Pseudomonas)

(day 3 EAB, day 11 removal of stent graft)

Results

Kaplan-Meier analysis

Actuarial survival Freedom from aortic event

(year) (year)

6 5 4 2 1 6 5 4 2 1

Discussion

EVAR for mycotic aneurysm (Kan et al, JVS 2007)EVAR is a possible alternative to treat this pathology,However, aneurysm of rupture and fever is a significant independentrisk factor for persistent infection.

vsOpen surgery TEVAR

Benefits

Drawbacks

Complete exclusion ofinfected aorta & esophagussimultaneouly

Less invasive therapy

High morbidity & mortalitydue to surgical invasiveness

Immediate hemostasis to stabilize hemodynamics

Difficulty to control severe infection

Staged hybrid therapy for aortic infection

1st : TEVAR= bridge to stabilize hemodynamics

2nd: Open surgery(EAB followed by removal of

infected aorta and esophagectomy)

to prevent persistent infection owing to stent graft infection

1st 2nd

1) TEVAR was an excellent modality to achieveimmediate hemostasis in the ruptured aortic infections.

2) Staged hybrid therapy might be effective forthe ruptured aortic infections.

Conclusions