1) Endovascular treatment of infected abdominal aortic aneurysms (AAAs) is an alternative to open surgery that provides less invasive and rapid aneurysm exclusion with prompt bleeding control. 2) Successful endovascular repair requires broad-spectrum antibiotics, adjunct procedures like surgical debridement for eliminating infection sources, and prolonged antibiotic therapy. 3) Endovascular repair alone may be sufficient for well-controlled infections, while unstable patients may require additional drainage; long-term antibiotic therapy is always needed.

1. KAMPHOL LAOHAPENSANG, MD, FACS,
Professor and Chief Division of Vascular and Endovascular Surgery,
Department of Surgery, Chiang Mai University Hospital,
Chiang Mai ,
Thailand
E-mail: klaohape@gmail.com
ENDOVASCULAR TREATMENT OF
INFECTED AAAS: IS SURGICAL DRAINAGE AND
DEBRIDEMENT ALWAYS NECESSARY?
14th Congress of Asian Society for Vascular and
Endovascular Surgery , October 28, 2013
Lütfi Kırdar International Congress and Exhibiton Center-
Rumeli Building / Istanbul, Turkey

2. • Missed and delayed diagnosis
• Immuno-compromised patients
• Located in para-visceral and thoraco-abdominal
aorta
Muller BT, et al. Mycotic aneurysms of the thoracic and abdominal aorta and iliac arteries. J Vasc Surg 2001; 33: 106-13.

3. • Positive blood culture specimen
• First presentation of an aneurysm after bacterial sepsis
• Positive culture from aneurysmal wall, its content or
the surrounding tissue with an associated infection
• Negative culture with
: Image finding of eccentric aneurysms
: Signs of infection
: Preoperative treatment with antibiotics
Muller BT, et al. Mycotic aneurysms. J Vasc Surg 2001; 33:106-113.

4. • Antibiotics: initial and long term
• Prompt surgical treatment: rupture risk
- Excision of infected artery
- Removal of surrounding infected tissue
• Arterial reconstruction
- In-situ graft replacement
- Extra-anatomical bypass

6. • Pus collection or extended inflammatory change of the
surrounding tissue
- Resection of the infected tissue
- Copious saline irrigation
- Closure of the aortic stump
- Extra-anatomical revascularization
• Low grade infection
- Resection of the infected tissue
- Copious saline irrigation
- In-situ Revascularization
- Omental pedicle

7. • Antibiotic-coated (Rifampicin) Dacron grafts
• PTFE grafts
• Silver coated polyester grafts
• Autogenous material
• Cryopreserved allografts

8. Batt M, et al. In situ revascularization with silver-coated polyester grafts to treat aortic infection. J Vasc Surg 2003;38: 983-9.

10. • Advantage of extra-anatomical bypass
- Decrease the risk of graft infection
• Advantage of in-situ graft replacement
- Possible in special anatomic sites
- Aortic arch
- Thoraco-abdominal aorta
- Para-visceral aorta

11. • Disadvantages of extra-anatomical bypass
- Shorter graft patency
- Aortic stump disruption 20%
- Amputation 20-29%
- Infection 20%
Oderich GS, Panneto JM, Bower TC, et al. Infected aortic aneueysms. J Vasc Surg 2001; 34 : 900-8.

12. ENDOGRAFTS FOR THE TREATMENT
OF INFECTED AORTIC ANEURYSMS
• An alternative to open surgery
• Less invasive, rapid aneurysm exclusion Prompt
control of bleeding in the face of hemodynamic
instability
• The better choice for critically ill patients with hostile
abdomen

13. ENDOGRAFTS FOR THE TREATMENT OF
INFECTED AORTIC ANEURYSMS

14. • Advantages
• Decrease surgical morbidity and mortality
• Temporary measure in ruptured infected AAA
• Disadvantages
• Retained foreign body in infected tissue
• Tissue arterial wall morphology could not be obtained.
• Uncertain long term outcomes

15. THE SUCCESSFUL USE OF EVAR IN
MYCOTIC AORTIC ANEURYSMS
1. Broad-spectrum antibiotics are administered as soon as a mycotic
aortic aneurysm is suspected
2. No microbes could be isolated from blood and tissue cultures in
25 % to 40 % of mycotic aortic aneurysms
3. The use of antibiotic-coated grafts to reduce the source of
infection
4. Adjunct procedures such as surgical debridement and
percutaneous drainage are an important step in eliminating the sou
rce of infection
5. Prolonged postoperative antibiotic therapy is a key component for
success
Lee KH, et al. J Endovasc Ther 2006; 13: 338-45.
Kan CD, Lee HL, Yang YJ. Outcome after endovascular stent graft treatment for mycotic aortic aneurysm: A systematic review.
J Vasc Surg 2007; 46: 906-12.

16. THE QUESTIONS TO BE ADDRESSED
1. When is endovascular repair only palliative therapy?
2. When does it serve as a bridge to staged definitive
surgical therapy?
3. When is endovascular repair the preferred, definitive
therapy?

17. THE ROLE OF EVAR FOR TREATMENT
OF INFECTED AORTIC ANEURYSMS
• Well- controlled of an active infection by broad-
spectrum antibiotics and with the patient without fever
and with stable hemodynamic parameters
• Acute presentation with fever, positive blood culture,
active bleeding and hemodynamic in-stability from
aneurysm rupture
• Treatment is followed by specific appropriate
antibiotics

18. CHIANG MAI UNIVERSITY REVIEW
(FROM JANUARY 2009 DECEMBER 2011)
Elective EVAR for stable Infected AAAs
Case
no.
Gender/Age Organisms Procedures Complications 2nd
Procedures Status
1. 71/ M Salmonella Bifurcated
Graft
Infected Graft Explantation
10 months after
EVAR
Alive
2. 69/ M B. pseudomallei AUI - FFbx No No Alive
3. 72/ M E. coli Bifurcated
Graft
No Surgical
Drainage
Alive
4. 83/ F Salmonella Tube Graft No No Alive
5. 57/ M B. pseudomallei Tube Graft No No Alive
All survived patients have a lifelong antibiotics treatment

19. EXPLANTANTATION OF THE INFECTED AORTIC
STENT GRAFT

20. EVAR for Mycotic Aortoiliac Aneurysm with
Surgical Drainage

21. EVAR for Mycotic Aortoiliac Aneurysm with Surgical
Drainage

22. CHIANG MAI UNIVERSITY REVIEW
(FROM JANUARY 2009 DECEMBER 2011)
All 5 cases ( 1 E. coli, 1 B. pseudomalei and 3 Salmonella )
• No operative and 30 days mortality
• Significant postoperative complications 40 %
-Renal failure, MI, respiratory failure, etc
• Surgical complications 21 %
-Bleeding, wound, ischemic colitis, etc
Elective Open repair for stable Infected AAAs
All survived patients have a lifelong antibiotics treatment
Laohapensang K, et al. Management of the Infected Aortoiliac Aneurysms. Annals of Vascular Disease 2012: 5 : 1-8.

23. CHIANG MAI UNIVERSITY REVIEW
(FROM JANUARY 2009 DECEMBER 2011)
Case no. Gender/Age Organisms Procedures Complications 2nd
Procedures Status
1. 75/ F Salmonella Bifurcated
Graft
Left Graft
Limb
Occlusionb
Thrombo-
embolectomy
Alive
2. 58/ M E. coli Tube Graft No No Alive
3. 81/ M Salmonella AUI , F-F bx No No Alive
4. 61/ F Salmonella Tube Graft No No Alive
Emergency EVAR for un-stable Infected AAAs
Emergency Open repair for un-stable Infected AAAs
All 5 case had Salmonella infection with 30 days mortality rate of 60 % (3/5)
All survived patients have a lifelong antibiotics treatment
Laohapensang K, et al. Management of the Infected Aortoiliac Aneurysms. Annals of Vascular Disease 2012: 5 : 1-8.
Laohapensang K, et al. Infected aneurysms. Annals of Vascular Disease 2010: 3 : 16-23.

24. SIRIRAJ HOSPITAL REVIEW
(FROM JANUARY 2009 DECEMBER 2012)
Stable 15 cases
• Microorganisms 2 Salmonella, 2 Staphylococcus, 1 E. coli, 8 NG
• Procedures 6 Tube Graft, 5 Bifurcated Graft, 3 AUI-FFbx, 1
Chimney
• Motalty rate 13.3% (2/15) 1 sepsis, 1 after explantation of
Infected Stent Graft
Emergency 5 cases
• Microorganisms 1 B. pseudomallei, 1 Salmonella, 3 NG
• Mortality rate 20% (1/15) 1 MOF
No surgical debridement and percutaneous drainage

25. IS SURGICAL DRAINAGE AND
DEBRIDEMENT ALWAYS NECESSARY?
THE ANSWER IS
NO

26. THANK YOU FOR ATTENTION
Chiang Mai,
Thailand