A 52-year-old man presented 33 months after thoracic aortic endovascular repair with hemoptysis and was found to have an aortobronchial fistula secondary to a mycotic aneurysm. The endograft infection was managed in a two-stage fashion. During the initial stage, the patient underwent an ascending-to-descending thoracic aortic bypass. Neither cardiopulmonary bypass, hypothermic circulatory arrest, nor aortic cross-clamping were used. During the same hospitalization, the patient underwent successful endograft explantation through a left thoracotomy. Imaging at 6 months demonstrated no anastomotic concerns and resolution of residual pulmonary inflammation. 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

Farber, Mark A.

Riesenman, Paul J.

Elsevier - Publisher Connector 

From the Southern Association for Vascular Surgery
Management of a thoracic endograft infection
through an ascending to descending extra-
anatomic aortic bypass and endograft explantation
Paul J. Riesenman, MD, MS, and Mark A. Farber, MD, Chapel Hill, NC
A 52-year-old man presented 33 months after thoracic aortic endovascular repair with hemoptysis and was found to have
an aortobronchial fistula secondary to a mycotic aneurysm. The endograft infection was managed in a two-stage fashion.
During the initial stage, the patient underwent an ascending-to-descending thoracic aortic bypass. Neither cardiopul-
monary bypass, hypothermic circulatory arrest, nor aortic cross-clamping were used. During the same hospitalization, the
patient underwent successful endograft explantation through a left thoracotomy. Imaging at 6 months demonstrated no
anastomotic concerns and resolution of residual pulmonary inflammation. Thoracic aortic endograft infections necessi-
tating endograft removal can potentially be successfully and safely managed without the need for cardiopulmonary
bypass, hypothermic circulatory arrest, or interruption of aortic blood flow. (J Vasc Surg 2010;51:207-9.)Endograft-related infections after thoracic endovascu-
lar aortic repair (TEVAR) are rarely reported but are a
devastating complication of aortic disease management.
Definitive treatment necessitates revascularization, open
surgical endograft explantation, and débridement of in-
fected tissue within the surgical field. This represents a
failure of the intended minimally invasive approach of
TEVAR and places the patient at increased risk of morbidity
and death from an urgent or emergency open surgical
intervention.
As endovascular interventions become more com-
monly applied to thoracic aortic pathology, secondary en-
dograft infections will undoubtedly be encountered at in-
stitutions in which these procedures are performed. The
application of less invasive surgical approaches that mini-
mize the operative risk to patients who require endograft
explantation in this setting would be beneficial.
CASE REPORT
A 52-year-old man was referred to our institution with a
history of recurrent hemoptysis. His medical history was significant
for a prior left thoracotomy and anterior spinal fusion of T7-T9 for
a vertebral compression fracture sustained as a complication of
multiple myeloma. Evaluation at the referring institution had
revealed a pseudoaneurysm in the descending thoracic aorta at the
From the Department of Surgery, Division of Vascular Surgery, University
of North Carolina.
Competition of interest: Dr Farber a consultant for W. L. Gore and Associ-
ates, Inc, Cook Inc, and Medtronic Inc.
Presented at the Thirty-third Annual Meeting of the Southern Association
for Vascular Surgery, Tucson, Ariz, Jan 14-17, 2009.
Reprint requests: Mark A. Farber, MD, Associate Professor, Division of
Vascular Surgery, University of North Carolina, CB #7212, 3024
Burnett-Womack Bldg, Chapel Hill, NC 27599-7212 (e-mail: mark_
farber@med.unc.edu).
The editors and reviewers of this article have no relevant financial relationships
to disclose per the JVS policy that requires reviewers to decline review of any
manuscript for which they may have a competition of interest.
0741-5214/$36.00
Copyright © 2010 by the Society for Vascular Surgery.
doi:10.1016/j.jvs.2009.07.097level of the patient’s spinal hardware. Cross-sectional imaging
showed no evidence of periaortic inflammation, and the pseudo-
aneurysm was assessed to have most likely been an iatrogenic
complication of the patient’s spinal surgery.
The patient underwent TEVAR and received a 26-mm 
10-cm Gore TAG endograft (W. L. Gore and Associates Inc,
Flagstaff, Ariz). The procedure was technically successful, and the
patient was discharged home on postoperative day 1. At the 1-year
follow-up, the patient reported no recurrence of hemoptysis, and
computed tomographic angiography (CTA) demonstrated suc-
cessful exclusion of the pseudoaneurysm. The patient did not
return for further follow-up.
The patient presented again with hemoptysis 33 months after
TEVAR and reported a 6-month history of treatment at a local
hospital for recurrent pseudomonal infections. CTA at that time
demonstrated resolution of the original pseudoaneurysm, pulmo-
nary infiltrates in the left lower lobe, and periaortic inflammation
with proximal and distal aortic aneurysmal formation around the
endograft (Fig 1). Blood and bronchial lavage cultures were posi-
tive for Pseudomonas aeruginosa. Intravenous (IV) antibiotics and
strict blood pressure control were initiated, and the hemoptysis
resolved.
The patient was assessed to be high risk for conventional repair
with anatomic interposition graft reconstruction given his previous
thoracotomy and the active infection with adjacent lung inflamma-
tion. To minimize the invasiveness of the surgical treatment and
avoid uncontrollable hemorrhage during operative exposure, a
two-stage approach was used.
In the first stage, the patient underwent an ascending-to-
descending thoracic aortic bypass through a median sternotomy.
The pericardium was opened longitudinally, exposing the ascend-
ing aorta. The diaphragm was divided near the midline, and the
distal descending thoracic aorta was dissected circumferentially.
Systemic heparinization was administered, and a side-biting clamp
was placed on the aorta at the level of the hiatus. A 16-mmDacron
graft (Hemashield, Meadox Medicals Inc, Oakland, NJ) was anas-
tomosed in an end-to-side fashion to the distal thoracic aorta and
tunneled into the mediastinum through the diaphragm just lateral
to the pericardium. The proximal anastomosis was fashioned in an
207
JOURNAL OF VASCULAR SURGERY
January 2010208 Riesenman and Farberend-to-side fashion to the right lateral aspect of the ascending aorta
(Fig 2). Neither cardiopulmonary bypass, hypothermic circulatory
arrest, nor complete aortic cross-clamping were used during the
procedure.
During the same hospitalization, the second stage of the
intervention was performed. The patient was placed in a lateral
decubitus position with external rotation of his hips to allow for
access to the left groin. Open access to the left femoral artery was
obtained with placement of a 20F sheath. To ensure vascular
control during exposure and dissection through the chest, two
endografts were deployed with proximal and distal overlap of the
original endoprosthesis (28-  10-mm and 26-  10-mm Gore
TAG components, respectively).
The left chest was entered through the fifth and eighth in-
terspaces. Proximal control of the aorta just distal to the left
subclavian artery and distal control of the distal descending aorta
was obtained. The proximal and distal ends of the thoracic aorta
were ligated with a 45-mm vascular stapler, and the staple lines
were reinforced with suture ligation. The lung was dissected off the
aorta, and a wedge resection of the lingual and a portion of the left
lower lobe was performed. The aorta was opened longitudinally,
and the three indwelling endografts were removed. Results of
intraoperative cultures of the infected aortic tissue were positive for
Pseudomonas.
The patient had an uncomplicated recovery from this proce-
dure and was discharged home on postoperative day 8 on a 6-week
course of IV gentamicin and ceftazidime. In follow-up at 6
months, he was asymptomatic off antibiotics, and CTA revealed
patency of the ascending-to-descending aortic bypass and resolu-
tion of the pulmonary inflammation (Fig 3). Eighteen months
after endograft explantation, the patient has continued to do well.
DISCUSSION
An incidence of endograft infection after endovascular
abdominal aortic aneurysm repair of 0.16% to 0.43% has
been reported.1,2 The incidence of thoracic endograft in-
fection after TEVAR is largely undefined at this time. The
most widely accepted approach for the treatment of in-
Fig 1. Computed tomography angiography of the chest demon-
strates periaortic inflammation and aneurysmal dilatation around
the endograft.fected abdominal aortic grafts and endografts is completeremoval of the graft or endoprosthesis, local débridement
of infected tissue, and extra-anatomic bypass through a
noninfected surgical field.3
For thoracic aortic graft and endograft infections, ana-
tomic limitations often necessitate in situ vascular recon-
struction within the infected field.4 A direct surgical ap-
proach to the thoracic aorta may be compromised by the
adjacent inflammatory response to lung parenchyma and
surrounding structures. Obtaining adequate exposure with
conventional proximal and distal vascular control may place
the patient at risk for life-threatening hemorrhage. Hem-
orrhage from lung parenchyma and surgical dissection
would also be exacerbated, and often extensive, by the use
of hypothermic arrest in this setting. Furthermore, ana-
Fig 2. Intraoperative photograph shows completion of the
ascending-to-descending thoracic aortic bypass.
Fig 3. A three-dimensional reconstruction of computed tomog-
raphy images obtained 6 months after thoracic endograft explan-
tation demonstrates patency of the ascending-to-descending aortic
bypass.tomic reconstruction in this setting places the new prosthe-
JOURNAL OF VASCULAR SURGERY
Volume 51, Number 1 Riesenman and Farber 209sis at risk for graft infection, which may lead to late infec-
tious complications.4 This approach may also necessitate
cardiopulmonary bypass, hypothermic arrest, and aortic
cross-clamping, which confers significant physiologic stress;
the avoidance of which was the intent of the initial endovas-
cular procedure.
Several authors have described the use of the ascending
aorta as a source of inflow for extra-anatomic bypass of
descending thoracic aortic lesions.5-16 Descriptions of dis-
tal aortic revascularization sites have included the descend-
ing thoracic aorta,11,12,15,16 the supraceliac abdominal
aorta,5-7,13 and the infrarenal abdominal aorta.7,10,14
Although most of these extra-anatomic ascending-to-distal
aortic bypass procedures have been for the treatment of
aortic coarctation,5,10-13,15,16 other reported applications
have included atherosclerotic aneurysms,7 infected aneu-
rysms,4,7 and infected prosthetic grafts.6 Some authors
have used cardiopulmonary bypass during the construction
of these bypasses for the treatment of coarctation to
ensure adequate perfusion during partial clamping of the
aorta.11,12 In the absence of a stenotic aortic lesion and
the use of partial aortic occlusion, cardiopulmonary would
be unnecessary.
A major benefit of this extra-anatomic surgical ap-
proach is that it provides a highly durable bypass that
supplies adequate distal blood flow to the mesentery and
lower extremities. McKeller et al12 reported their single-
institution series of 50 patients who underwent ascending–
descending aortic bypass for coarctation. No graft occlu-
sion or pseudoaneurysm formation was reported through a
mean follow-up of 33 months, with 74% of grafts under-
going imaging evaluation.
Another useful adjunct in our surgical approach was the
deployment of additional thoracic endografts proximally
and distally to the original endoprosthesis to protect the
patient from hemorrhage during the long second stage of
the procedure. We did not exclude the patient’s mycotic
aneurysm at the time of presentation because the hemop-
tysis resolved and we wanted to avoid aggravation of the
infected vascular territory. The use of additional thoracic
endograft components to stabilize the patient or facilitate
vascular control should be considered in anatomically ac-
ceptable candidates.
CONCLUSION
Extra-anatomic ascending-to-descending thoracic aor-
tic bypass for the treatment of infected thoracic endografts
offers a durable form of vascular reconstruction that avoids
the placement of a prosthesis within the contaminated fieldand facilitates endograft explantation without the use of
cardiopulmonary bypass or interruption of aortic blood
flow. This approach may be especially beneficial in patients
who have associated lung pathology or who have under-
gone prior thoracotomy.
REFERENCES
1. Vogel TR, Symons R, Flum DR. The incidence and factors associated
with graft infection after aortic aneurysm repair. J Vasc Surg 2008;47:
264-9.
2. Ducasse E, Calisti A, Speziale F, Rizzo L, Misuraca M, Fiorani P.
Aortoiliac stent graft infection: current problems andmanagement. Ann
Vasc Surg 2004;18:521-6.
3. Seeger JM, Pretus HA, Welborn MB, Ozaki CK, Flynn TC, Huber TS.
Long-term outcome after treatment of aortic graft infection with staged
extra-anatomic bypass grafting and aortic graft removal. J Vasc Surg
2000;32:451-9; discussion 460-1.
4. Coselli JS, Koksoy C, LeMaire SA. Management of thoracic aortic graft
infections. Ann Thorac Surg 1999;67:1990-3; discussion 1997-8.
5. Yamamoto S, Sasaguri S, Fukuda T, Hosoda Y. Ascending aorta to
supraceliac abdominal aorta bypass for coarctation of the aorta in an
adult. Surg Today 1997;27:288-90.
6. Odagiri S, Itoh T, Yozu R, Kawada K, Inoue T. Ascending aorta-
supraceliac abdominal aorta bypass: successful removal of an infected
graft in the descending thoracic aorta. Chest 1979;75:722-4.
7. Kieffer E, Petitjean C, Richard T, Godet G, Dhobb M, Ruotolo C.
Exclusion-bypass for aneurysms of the descending thoracic and thora-
coabdominal aorta. Ann Vasc Surg 1986;1:182-95.
8. Izhar U, Schaff HV, Mullany CJ, Daly RC, Orszulak TA. Posterior
pericardial approach for ascending aorta-to-descending aorta bypass
through a median sternotomy. Ann Thorac Surg 2000;70:31-7.
9. Connolly HM, Schaff HV, Izhar U, Dearani JA, Warnes CA, Orszulak
TA. Posterior pericardial ascending-to-descending aortic bypass: an
alternative surgical approach for complex coarctation of the aorta.
Circulation 2001;104(12 suppl 1):I133-7.
10. Robicsek F, Hess PJ, Vajtai P. Ascending-distal abdominal aorta bypass
for treatment of hypoplastic aortic arch and atypical coarctation in the
adult. Ann Thorac Surg 1984;37:261-3.
11. Aoyagi S, Fukunaga S, Tayama E, Yoshida T. Extraanatomic aortic
bypass for repair of aortic coarctation. J Card Surg 2007;22:436-9.
12. McKellar SH, Schaff HV, Dearani JA, Daly RC, Mullany CJ, Orszulak
TA, et al. Intermediate-term results of ascending-descending posterior
pericardial bypass of complex aortic coarctation. J Thorac Cardiovasc
Surg 2007;133:1504-9.
13. WukaschDC, Cooley DA, Sandiford FM,Nappi G, Reul GJ Jr. Ascend-
ing aorta-abdominal aorta bypass: indications, technique, and report of
12 patients. Ann Thorac Surg 1977;23:442-8.
14. Liotta D, Donato FO, Bertolozzi E. Staphylococcal aortic pseudoan-
eurysm. Treatment employing ascending aorta-abdominal aorta bypass
graft. Chest 1977;72:243-5.
15. SweeneyMS,WalkerWE, Duncan JM,Hallman GL, Livesay JJ, Cooley
DA. Reoperation for aortic coarctation: techniques, results, and indica-
tions for various approaches. Ann Thorac Surg 1985;40:46-9.
16. Jacob T, Cobanoglu A, Starr A. Late results of ascending aorta-descending
aorta bypass grafts for recurrent coarctation of aorta. J Thorac Cardio-
vasc Surg 1988;95:782-7.Submitted Jun 11, 2009; accepted Jul 23, 2009.


Management of a thoracic endograft infection through an ascending to descending extra-anatomic aortic bypass and endograft explantation 

Carolina Digital Repository

From the Southern Association for Vascular SurgeryManagement of a thoracic endograft infectionthrough an ascending to descending extra-anatomic aortic bypass and endograft explantationPaul J. Riesenman, MD, MS, and Mark A. Farber, MD, Chapel Hill, NCA 52-year-old man presented 33 months after thoracic aortic endovascular repair with hemoptysis and was found to havean aortobronchial fistula secondary to a mycotic aneurysm. The endograft infection was managed in a two-stage fashion.During the initial stage, the patient underwent an ascending-to-descending thoracic aortic bypass. Neither cardiopul-monary bypass, hypothermic circulatory arrest, nor aortic cross-clamping were used. During the same hospitalization, thepatient underwent successful endograft explantation through a left thoracotomy. Imaging at 6 months demonstrated noanastomotic concerns and resolution of residual pulmonary inflammation. Thoracic aortic endograft infections necessi-tating endograft removal can potentially be successfully and safely managed without the need for cardiopulmonarybypass, hypothermic circulatory arrest, or interruption of aortic blood flow. (J Vasc Surg 2010;51:207-9.)Endograft-related infections after thoracic endovascu-lar aortic repair (TEVAR) are rarely reported but are adevastating complication of aortic disease management.Definitive treatment necessitates revascularization, opensurgical endograft explantation, and débridement of in-fected tissue within the surgical field. This represents afailure of the intended minimally invasive approach ofTEVAR and places the patient at increased risk of morbidityand death from an urgent or emergency open surgicalintervention.As endovascular interventions become more com-monly applied to thoracic aortic pathology, secondary en-dograft infections will undoubtedly be encountered at in-stitutions in which these procedures are performed. Theapplication of less invasive surgical approaches that mini-mize the operative risk to patients who require endograftexplantation in this setting would be beneficial.CASE REPORTA 52-year-old man was referred to our institution with ahistory of recurrent hemoptysis. His medical history was significantfor a prior left thoracotomy and anterior spinal fusion of T7-T9 fora vertebral compression fracture sustained as a complication ofmultiple myeloma. Evaluation at the referring institution hadrevealed a pseudoaneurysm in the descending thoracic aorta at theFrom the Department of Surgery, Division of Vascular Surgery, Universityof North Carolina.Competition of interest: Dr Farber a consultant for W. L. Gore and Associ-ates, Inc, Cook Inc, and Medtronic Inc.Presented at the Thirty-third Annual Meeting of the Southern Associationfor Vascular Surgery, Tucson, Ariz, Jan 14-17, 2009.Reprint requests: Mark A. Farber, MD, Associate Professor, Division ofVascular Surgery, University of North Carolina, CB #7212, 3024Burnett-Womack Bldg, Chapel Hill, NC 27599-7212 (e-mail: mark_farber@med.unc.edu).The editors and reviewers of this article have no relevant financial relationshipsto disclose per the JVS policy that requires reviewers to decline review of anymanuscript for which they may have a competition of interest.0741-5214/$36.00Copyright © 2010 by the Society for Vascular Surgery.doi:10.1016/j.jvs.2009.07.097level of the patient’s spinal hardware. Cross-sectional imagingshowed no evidence of periaortic inflammation, and the pseudo-aneurysm was assessed to have most likely been an iatrogeniccomplication of the patient’s spinal surgery.The patient underwent TEVAR and received a 26-mm 10-cm Gore TAG endograft (W. L. Gore and Associates Inc,Flagstaff, Ariz). The procedure was technically successful, and thepatient was discharged home on postoperative day 1. At the 1-yearfollow-up, the patient reported no recurrence of hemoptysis, andcomputed tomographic angiography (CTA) demonstrated suc-cessful exclusion of the pseudoaneurysm. The patient did notreturn for further follow-up.The patient presented again with hemoptysis 33 months afterTEVAR and reported a 6-month history of treatment at a localhospital for recurrent pseudomonal infections. CTA at that timedemonstrated resolution of the original pseudoaneurysm, pulmo-nary infiltrates in the left lower lobe, and periaortic inflammationwith proximal and distal aortic aneurysmal formation around theendograft (Fig 1). Blood and bronchial lavage cultures were posi-tive for Pseudomonas aeruginosa. Intravenous (IV) antibiotics andstrict blood pressure control were initiated, and the hemoptysisresolved.The patient was assessed to be high risk for conventional repairwith anatomic interposition graft reconstruction given his previousthoracotomy and the active infection with adjacent lung inflamma-tion. To minimize the invasiveness of the surgical treatment andavoid uncontrollable hemorrhage during operative exposure, atwo-stage approach was used.In the first stage, the patient underwent an ascending-to-descending thoracic aortic bypass through a median sternotomy.The pericardium was opened longitudinally, exposing the ascend-ing aorta. The diaphragm was divided near the midline, and thedistal descending thoracic aorta was dissected circumferentially.Systemic heparinization was administered, and a side-biting clampwas placed on the aorta at the level of the hiatus. A 16-mm Dacrongraft (Hemashield, Meadox Medicals Inc, Oakland, NJ) was anas-tomosed in an end-to-side fashion to the distal thoracic aorta andtunneled into the mediastinum through the diaphragm just lateralto the pericardium. The proximal anastomosis was fashioned in an207JOURNAL OF VASCULAR SURGERYJanuary 2010208 Riesenman and Farberend-to-side fashion to the right lateral aspect of the ascending aorta(Fig 2). Neither cardiopulmonary bypass, hypothermic circulatoryarrest, nor complete aortic cross-clamping were used during theprocedure.During the same hospitalization, the second stage of theintervention was performed. The patient was placed in a lateraldecubitus position with external rotation of his hips to allow foraccess to the left groin. Open access to the left femoral artery wasobtained with placement of a 20F sheath. To ensure vascularcontrol during exposure and dissection through the chest, twoendografts were deployed with proximal and distal overlap of theoriginal endoprosthesis (28-  10-mm and 26-  10-mm GoreTAG components, respectively).The left chest was entered through the fifth and eighth in-terspaces. Proximal control of the aorta just distal to the leftsubclavian artery and distal control of the distal descending aortawas obtained. The proximal and distal ends of the thoracic aortawere ligated with a 45-mm vascular stapler, and the staple lineswere reinforced with suture ligation. The lung was dissected off theaorta, and a wedge resection of the lingual and a portion of the leftlower lobe was performed. The aorta was opened longitudinally,and the three indwelling endografts were removed. Results ofintraoperative cultures of the infected aortic tissue were positive forPseudomonas.The patient had an uncomplicated recovery from this proce-dure and was discharged home on postoperative day 8 on a 6-weekcourse of IV gentamicin and ceftazidime. In follow-up at 6months, he was asymptomatic off antibiotics, and CTA revealedpatency of the ascending-to-descending aortic bypass and resolu-tion of the pulmonary inflammation (Fig 3). Eighteen monthsafter endograft explantation, the patient has continued to do well.DISCUSSIONAn incidence of endograft infection after endovascularabdominal aortic aneurysm repair of 0.16% to 0.43% hasbeen reported.1,2 The incidence of thoracic endograft in-fection after TEVAR is largely undefined at this time. Themost widely accepted approach for the treatment of in-Fig 1. Computed tomography angiography of the chest demon-strates periaortic inflammation and aneurysmal dilatation aroundthe endograft.fected abdominal aortic grafts and endografts is completeremoval of the graft or endoprosthesis, local débridementof infected tissue, and extra-anatomic bypass through anoninfected surgical field.3For thoracic aortic graft and endograft infections, ana-tomic limitations often necessitate in situ vascular recon-struction within the infected field.4 A direct surgical ap-proach to the thoracic aorta may be compromised by theadjacent inflammatory response to lung parenchyma andsurrounding structures. Obtaining adequate exposure withconventional proximal and distal vascular control may placethe patient at risk for life-threatening hemorrhage. Hem-orrhage from lung parenchyma and surgical dissectionwould also be exacerbated, and often extensive, by the useof hypothermic arrest in this setting. Furthermore, ana-Fig 2. Intraoperative photograph shows completion of theascending-to-descending thoracic aortic bypass.Fig 3. A three-dimensional reconstruction of computed tomog-raphy images obtained 6 months after thoracic endograft explan-tation demonstrates patency of the ascending-to-descending aorticbypass.tomic reconstruction in this setting places the new prosthe-JOURNAL OF VASCULAR SURGERYVolume 51, Number 1 Riesenman and Farber 209sis at risk for graft infection, which may lead to late infec-tious complications.4 This approach may also necessitatecardiopulmonary bypass, hypothermic arrest, and aorticcross-clamping, which confers significant physiologic stress;the avoidance of which was the intent of the initial endovas-cular procedure.Several authors have described the use of the ascendingaorta as a source of inflow for extra-anatomic bypass ofdescending thoracic aortic lesions.5-16 Descriptions of dis-tal aortic revascularization sites have included the descend-ing thoracic aorta,11,12,15,16 the supraceliac abdominalaorta,5-7,13 and the infrarenal abdominal aorta.7,10,14Although most of these extra-anatomic ascending-to-distalaortic bypass procedures have been for the treatment ofaortic coarctation,5,10-13,15,16 other reported applicationshave included atherosclerotic aneurysms,7 infected aneu-rysms,4,7 and infected prosthetic grafts.6 Some authorshave used cardiopulmonary bypass during the constructionof these bypasses for the treatment of coarctation toensure adequate perfusion during partial clamping of theaorta.11,12 In the absence of a stenotic aortic lesion andthe use of partial aortic occlusion, cardiopulmonary wouldbe unnecessary.A major benefit of this extra-anatomic surgical ap-proach is that it provides a highly durable bypass thatsupplies adequate distal blood flow to the mesentery andlower extremities. McKeller et al12 reported their single-institution series of 50 patients who underwent ascending–descending aortic bypass for coarctation. No graft occlu-sion or pseudoaneurysm formation was reported through amean follow-up of 33 months, with 74% of grafts under-going imaging evaluation.Another useful adjunct in our surgical approach was thedeployment of additional thoracic endografts proximallyand distally to the original endoprosthesis to protect thepatient from hemorrhage during the long second stage ofthe procedure. We did not exclude the patient’s mycoticaneurysm at the time of presentation because the hemop-tysis resolved and we wanted to avoid aggravation of theinfected vascular territory. The use of additional thoracicendograft components to stabilize the patient or facilitatevascular control should be considered in anatomically ac-ceptable candidates.CONCLUSIONExtra-anatomic ascending-to-descending thoracic aor-tic bypass for the treatment of infected thoracic endograftsoffers a durable form of vascular reconstruction that avoidsthe placement of a prosthesis within the contaminated fieldand facilitates endograft explantation without the use ofcardiopulmonary bypass or interruption of aortic bloodflow. This approach may be especially beneficial in patientswho have associated lung pathology or who have under-gone prior thoracotomy.REFERENCES1. Vogel TR, Symons R, Flum DR. The incidence and factors associatedwith graft infection after aortic aneurysm repair. J Vasc Surg 2008;47:264-9.2. Ducasse E, Calisti A, Speziale F, Rizzo L, Misuraca M, Fiorani P.Aortoiliac stent graft infection: current problems and management. AnnVasc Surg 2004;18:521-6.3. Seeger JM, Pretus HA, Welborn MB, Ozaki CK, Flynn TC, Huber TS.Long-term outcome after treatment of aortic graft infection with stagedextra-anatomic bypass grafting and aortic graft removal. J Vasc Surg2000;32:451-9; discussion 460-1.4. Coselli JS, Koksoy C, LeMaire SA. Management of thoracic aortic graftinfections. Ann Thorac Surg 1999;67:1990-3; discussion 1997-8.5. Yamamoto S, Sasaguri S, Fukuda T, Hosoda Y. Ascending aorta tosupraceliac abdominal aorta bypass for coarctation of the aorta in anadult. Surg Today 1997;27:288-90.6. Odagiri S, Itoh T, Yozu R, Kawada K, Inoue T. Ascending aorta-supraceliac abdominal aorta bypass: successful removal of an infectedgraft in the descending thoracic aorta. Chest 1979;75:722-4.7. Kieffer E, Petitjean C, Richard T, Godet G, Dhobb M, Ruotolo C.Exclusion-bypass for aneurysms of the descending thoracic and thora-coabdominal aorta. Ann Vasc Surg 1986;1:182-95.8. Izhar U, Schaff HV, Mullany CJ, Daly RC, Orszulak TA. Posteriorpericardial approach for ascending aorta-to-descending aorta bypassthrough a median sternotomy. Ann Thorac Surg 2000;70:31-7.9. Connolly HM, Schaff HV, Izhar U, Dearani JA, Warnes CA, OrszulakTA. Posterior pericardial ascending-to-descending aortic bypass: analternative surgical approach for complex coarctation of the aorta.Circulation 2001;104(12 suppl 1):I133-7.10. Robicsek F, Hess PJ, Vajtai P. Ascending-distal abdominal aorta bypassfor treatment of hypoplastic aortic arch and atypical coarctation in theadult. Ann Thorac Surg 1984;37:261-3.11. Aoyagi S, Fukunaga S, Tayama E, Yoshida T. Extraanatomic aorticbypass for repair of aortic coarctation. J Card Surg 2007;22:436-9.12. McKellar SH, Schaff HV, Dearani JA, Daly RC, Mullany CJ, OrszulakTA, et al. Intermediate-term results of ascending-descending posteriorpericardial bypass of complex aortic coarctation. J Thorac CardiovascSurg 2007;133:1504-9.13. Wukasch DC, Cooley DA, Sandiford FM, Nappi G, Reul GJ Jr. Ascend-ing aorta-abdominal aorta bypass: indications, technique, and report of12 patients. Ann Thorac Surg 1977;23:442-8.14. Liotta D, Donato FO, Bertolozzi E. Staphylococcal aortic pseudoan-eurysm. Treatment employing ascending aorta-abdominal aorta bypassgraft. Chest 1977;72:243-5.15. Sweeney MS, Walker WE, Duncan JM, Hallman GL, Livesay JJ, CooleyDA. Reoperation for aortic coarctation: techniques, results, and indica-tions for various approaches. Ann Thorac Surg 1985;40:46-9.16. Jacob T, Cobanoglu A, Starr A. Late results of ascending aorta-descendingaorta bypass grafts for recurrent coarctation of aorta. J Thorac Cardio-vasc Surg 1988;95:782-7.Submitted Jun 11, 2009; accepted Jul 23, 2009.

Management of a thoracic endograft infection through an ascending to descending extra-anatomic aortic bypass and endograft explantation

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Management of a thoracic endograft infection through an ascending to descending extra-anatomic aortic bypass and endograft explantation

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