Optimizing treatment of proximal thoracic aortic graft infections.

OBJECTIVES: To describe treatment, assess outcomes, and identify risk factors for primary infection, reinfection, and death in patients with proximal thoracic aortic graft infection. METHODS: From July 2007 to January 2018, 148 adults received treatment for graft infection of the aortic root (108 [73%]), ascending aorta (100 [68%]), and aortic arch (5 [3.4%]) at a median 2.7 years after implant. Median follow-up after diagnosis of graft infection was 2.8 years. Multiphase hazard modeling was used to determine instantaneous risk of infection and death. Multivariable regression and random forests were implemented to identify risk factors for time to infection, reinfection, and death. RESULTS: Patients presented with fever (108 [73%]), chest pain (66 [45%]), embolic ischemia (31 [21%]), or stroke (13 [8.8%]). One hundred forty (95%) patients underwent surgery, including 126 (85%) with complete graft excision and replacement, usually with an allograft. There were 3 (2%) hospital deaths. Seven-year freedom from reinfection was 79%. Graft excision and replacement with an allograft mitigated risk of reinfection, and history of intravenous drug use was a risk factor for reinfection. Survival at 1, 5, and 8 years was 84%, 72%, and 57%, respectively. Nonsurgical management, fungal pathogen, and stroke as a presenting symptom of graft infection were risk factors for early death. CONCLUSIONS: Proximal aortic graft infections should be treated with prompt, tailored antibiotic therapy followed by complete graft excision. We recommend graft replacement with an allograft for its versatility as a conduit and its potential to mitigate reinfection.