Management of a Thoracic Endograft Infection Through Ascending to Descending Extra-Anatomic Aortic Bypass and Endograft Explantation

BACKGROUND: Thoracic endograft infections are rare and management of this condition necessitates removal of the infected endoprosthesis. We report a case of a patient who presented with an aortobronchial fistula associated with an endograft infection several years after thoracic endovascular aortic repair who was successfully treated with extra-anatomic aortic bypass, adjunctive endovascular exclusion of the fistula, and endograft explantation.
METHODS: A 52 year-old man with a history of multiple myeloma underwent thoracic endovascular aortic repair for a pseudoaneurysm that developed as a complication of spinal surgery. The patient presented 33 months after endovascular repair with hemoptysis and was found to have an aortobronchial fistula secondary to a Pseudomonal mycotic aneurysm associated with his endograft. CT angiography at the time of presentation demonstrated resolution of the original pseudoaneurysm, pulmonary infiltrates in the left lower lobe, and periaortic inflammation with proximal and distal aortic aneurysmal formation around the endograft (Figure 1). Due to previous thoracic surgery, the endograft infection was managed in a two-stage fashion. During the initial stage, the patient underwent an ascending to descending thoracic aortic bypass through a median sternotomy. Neither cardiopulmonary bypass, hypothermic circulatory arrest, nor aortic cross-clamping were utilized to construct the bypass. After partial recovery the patient underwent thoracic endograft explantation through a left thoracotomy with wedge resection of the left lower lobe. The patient was protected from hemorrhage during the long second stage by placing proximal and distal thoracic endograft components to exclude the fistula.
RESULTS: The patient made a full recovery without complications. Imaging at 6 months demonstrated no anastomotic concerns and resolution of residual pulmonary inflammation (Figure 2).
CONCLUSIONS: Thoracic aortic endograft infections necessitating endograft removal can potentially be successfully and safely managed without the need for cardiopulmonary bypass, hypothermic circulatory arrest, or interruption of aortic blood flow.