Nationwide Study of the Treatment of Mycotic Abdominal Aortic Aneurysms Comparing Open and Endovascular RepairClinical Perspective
Background: No reliable comparative data exist between open repair (OR) and endovascular aneurysm repair (EVAR) for mycotic abdominal aortic aneurysms (MAAAs). This nationwide study assessed outcomes after OR and EVAR for MAAA in a population-based cohort.
Methods: All patients treated for MAAAs in Sweden between 1994 and 2014 were identified in the Swedish vascular registry. The primary aim was to assess survival after MAAA with OR and EVAR. Secondary aims were analyses of the rate of recurrent infections and reoperations, and time trends in surgical treatment. Survival was analyzed using Kaplan-Meier and log-rank tests. A propensity score–weighted correction for risk factor differences in the 2 groups was performed, including the operation year to account for differences in treatment and outcomes over time.
Results: We identified 132 patients (0.6% of all operated abdominal aortic aneurysms in Sweden). Mean age was 70 years (standard deviation, 9.2), and 50 presented with rupture. Survival at 3 months was 86% (95% confidence interval, 80%–92%), at 1 year 79% (72%–86%), and at 5 years 59% (50%–68%). The preferred operative technique shifted from OR to EVAR after 2001 (proportion EVAR 1994–2000 0%, 2001–2007 58%, 2008–2014 60%). Open repair was performed in 62 patients (47%): aortic resection and extra-anatomic bypass (n=7), in situ reconstruction (n=50), and patch plasty (n=3); 2 patients died intraoperatively. EVAR was performed in 70 patients (53%): standard EVAR (n=55), fenestrated/branched EVAR (n=8), and visceral deviation with stent grafting (n=7); no deaths occurred intraoperatively. Survival at 3 months was lower for OR than for EVAR (74% versus 96%, P<0.001), with a similar trend present at 1 year (73% versus 84%, P=0.054). A propensity score–weighted risk-adjusted analysis confirmed the early better survival associated with EVAR. During median follow-up of 36 and 41 months for OR and EVAR, respectively, there was no difference in long-term survival (5 years 60% versus 58%, P=0.771), infection-related complications (18% versus 24%, P=0.439), or reoperation (21% versus 24%, P=0.650).
Conclusion: This study demonstrates a paradigm shift in treatment of MAAA in Sweden, with EVAR being the preferred treatment modality. EVAR was associated with improved short-term survival in comparison with OR, without higher associated incidence of serious infection-related complications or reoperations.
- aneurysm, infected
- aortic aneurysm, abdominal
- endovascular procedures
- open repair
Mycotic aortic aneurysm (MAA) is a term coined by Sir William Osler in 1885, and is a misnomer for aortic infection (usually bacterial) with subsequent aneurysm development.1 This is a rare but serious disease. The incidence of MAA has been estimated to be 0.6% to 2% of all aortic aneurysms in Western countries, and up to 13% in Taiwan.2–6 MAAs have a tendency to grow rapidly with high risk of rupture, and the patients often have severe comorbidities, in particular, immunodeficiency and coexisting septic conditions.7,8
Successful management relates to early diagnosis and expedient treatment comprising surgery and antibiotics. Traditional surgical management consists of open repair (OR) with debridement of the infected area followed by revascularization with in situ grafting with autologous vein or infection-resistant graft material, alternatively aortic ligation and extra-anatomic bypass. OR has the major advantage of infection control by resection of the infected tissue, but carries high mortality and morbidity with risk of late serious complications such as aortic stump blow-out.7,9 Furthermore, the anatomic location of the aneurysm sometimes makes surgical repair technically very demanding.10 Since 1998, endovascular aneurysm repair (EVAR) has been performed for MAAs.11 EVAR is a less invasive treatment option suitable for surgical high-risk patients, but a major disadvantage is the placement of the stent graft in an infected field, which is not resected, and thus may result in recurrent sepsis, stent graft infection, and development of recurrent MAA.12
Lack of data from comparative studies or randomized controlled trials results in limitations of guidelines for the management of MAAs. Most published case-series on MAAs are small and usually single center, including both thoracic and abdominal MAAs, and with inadequate follow-up.12–18 Consequently, information is heterogeneous, making comparison of outcomes difficult for OR versus EVAR. Open repair has been the long-established practice in the management of MAA and, despite lack of evidence, it is still considered the gold standard. Although EVAR for MAAs has been reported as a viable option, direct comparison with OR is difficult to perform because of the rareness and heterogeneity of the disease. A noncomparative European multicenter study of EVAR for MAA showed acceptable results for endovascular treatment, but lacked data on outcomes of OR.12
This article assesses surgical practice in Sweden for treatment of mycotic aneurysms of the abdominal aorta (MAAAs) on the basis of the national Swedish vascular registry (Swedvasc). All MAAA repairs performed nationwide over a 21-year period are included in this analysis. The primary aim was to assess short- and long-term survival after MAAA repair with open and endovascular techniques. Secondary aims included analyses of the rate of recurrent infections and reoperations, and time trends in surgical treatment, as well.
All patients treated for MAAAs between 1994 and 2014 were identified through the national Swedish vascular registry, Swedvasc. Swedvasc has been extensively validated internally, and externally against administrative hospital databases, as well.19,20 These validations ensure that the registry includes the absolute majority of patients undergoing aortic intervention in Sweden (93% to 99% external validity) with no difference in survival outcome among cases registered in the Swedvasc compared with the few that are not captured by the registry.19,20 Mortality data are 100% accurate thanks to matched computer files with the Swedish mortality registry. All 27 centers, which had prospectively registered an operation for MAAA, listed in the collaborator list (online-only Data Supplement Appendix A), participated in retrieving data.
An MAAA was defined as a combination of the following 3 criteria: (1) clinical presentation (pain, fever ≥38°C, sepsis, and concomitant infection), (2) laboratory tests (elevation of inflammatory markers like C-reactive protein and white blood cells, and positive cultures), and (3) radiological findings on computed tomography or MRI on the abdominal part of the aorta (rapid expansion of aneurysm, saccular aneurysm, multilobular aneurysms/eccentric aneurysms, periaortic gas, and periaortic soft tissue mass). Patients who had graft infections, aortoenteric and graft-enteric fistulae, inflammatory aneurysms, and who had previously had aortic surgery were excluded. An infection-related complication was defined as recurrent sepsis, graft or stent graft infection, aortoenteric fistula, or recurrence of a new MAA, in the same or at a different location. The term renal insufficiency was defined as a creatinine level of >1.70 mg/dL or the presence of renal replacement therapy.
All cases were retrospectively reviewed, applying a common study protocol (online-only Data Supplement Appendix B) including data on the following: (1) patient characteristics and clinical presentation (sex, age, medical history, immunodeficiency [including comorbidities and treatments associated with relative immunodeficiency], symptoms, concurrent infection, blood tests, and microbiological cultures); (2) aneurysm characteristics (aneurysm status, location, computed tomography findings: rapid expansion, saccular, multilobular, periaortic gas, periaortic mass); (3) treatment (open repair or endovascular approach, hybrid: combined open and endovascular repair, and antibiotic treatment); and (4) follow-up time, outcome, and complications. Survival was cross-matched with the Swedish population registry. All study protocols were sent to Uppsala for secondary reviews (K.S. and K.M.).
Primary outcome was overall survival, compared in the OR and EVAR groups, respectively. Secondary outcomes were defined as rate of recurrence of infection, rate of reoperation, and time trends in treatment and outcome. The cohort was divided into 3 time periods (1994–2000, 2001–2007, and 2008–2014), and data were analyzed regarding changes in treatment strategy and outcome over time. The incidence of MAAA repair was assessed as the proportion of all abdominal aortic aneurysm (AAA) repairs registered in the Swedish vascular registry. Comparative analyses were performed for the first 90 days and 1 year after surgery as short-term outcome, and long-term outcome at the intervals of 5 years and 10 years of MAAA repair on the basis of treatment strategy.
Data were analyzed using a statistical software package (SPSS 22, IBM Corporation). Data were assessed for normality with histograms. Continuous data were expressed as median (range), or mean (standard deviation) and categorical variables as proportions (%). All statistical tests were 2-tailed, and P<0.05 was considered significant. Correction for multiple testing was not performed to reduce risk of type II error. Differences between patients receiving OR and EVAR were tested using the χ2 test, or the independent samples t test for continuous variables. Logistic regression (for perioperative mortality) and Cox regression (for long-term mortality) analyses were performed to assess predictors of postoperative mortality. Factors with a P value of <0.2 in the univariable analysis were included in a forced-entry multivariable analysis.
Survival analyses were performed according to Kaplan-Meier, and differences in survival were assessed with the log rank test. For comparison of OR and EVAR, an additional survival analysis was performed with propensity score–weighted correction for risk factor differences in the 2 groups. This analysis was performed with the calculation of a propensity score for EVAR treatment on the basis of 15 covariables (age, sex, comorbidities, patient characteristics at presentation, aneurysm characteristics, blood culture results, and operation year) after multiple imputation of missing data (15 imputed data sets). Weighted survival estimates were calculated with Cox proportional hazard modeling. To analyze differences between OR and EVAR regarding infection-related death, a competing risk analysis was performed, assessing the risk of infection-related death with other causes of death as competing risk. The last 2 statistical analyses were performed using statistical software package cmprsk in R14 (Foundation for Statistical Computing21), and the estimation of confidence intervals and P values for these analyses were performed using 10 000 bootstrap simulations.
The study was approved by the Regional ethical review board in Uppsala, which also waived the need for informed consent.
A total of 184 cases of MAAAs were identified in Swedvasc. After case review, 52 were excluded as described in the consort diagram (Figure 1). Thus, a total of 132 patients treated for MAAA were included in the study.
Overall Results and Time Trends
The total number of repairs in the 3 periods were 1994 to 2000 n=14, 2001 to 2007 n=43, and 2008 to 2014 n=75 (Figure 2). The incidence of MAAA treatment as a proportion of all (intact and ruptured) AAA repairs in Sweden was 0.6% (1994–2000, 0.2%; 2001–2007, 0.6%; and 2008–2014, 0.9%). EVAR for MAAA was first introduced in late 2001, and has since constituted 59% of MAAA repairs.
Table 1 presents demographics, laboratory results, aneurysm characteristics, and radiological features of the patients. Eight patients had multiple MAAAs: infrarenal and paravisceral (n=3), infrarenal and 2 paravisceral (n=1), 2 paravisceral (n=1), 3 infrarenal (n=1), infrarenal and thoracic (n=1), and paravisceral and 3 thoracic (n=1). At least 1 positive blood culture was achieved in two-thirds of the patients (for details, see online-only Data Supplement Table I). The 3 most prevalent infectious agents were Streptococcus species (n=29, 22% of all patients), Staphylococcus species (n=21, 16%), and Salmonella species (n=12, 9%).
OR was performed in 62 patients (47%): aortic resection and extra-anatomic bypass (n=7), in situ reconstruction (n=50), and patch plasty (n=3); 2 died intraoperatively during the OR attempt. EVAR was performed in 70 patients (53%): standard EVAR (n=55), fenestrated EVAR (n=5), branched EVAR (n=3), and hybrid visceral deviation and stent grafting (n=7); no patients died intraoperatively during EVAR procedures. Antibiotics were administered for a median of 12 weeks (range, 0–360): OR, 8 weeks (0–360); and EVAR 16 weeks (1–156), P=0.478. Eight patients (OR n=2, 3.2%; EVAR n=6, 8.6%; P=0.040) had adjunctive percutaneous drainage of abscesses.
Surgical outcomes are presented in Table 2. The mean follow-up time among survivors (>90 days) was 64 months (range, 3–324). Kaplan-Meier estimates of overall survival at 3 months was 86% (95% confidence interval, 80%–92%), 1 year 79% (72%–86%), 5 years 59% (50%–68%), and 10 years 39% (27%–51%). Three-month survival was 71% during 1994 to 2000, 88% during 2001 to 2007, and 87% during 2008 to 2014, P=0.253, and differed between intact MAAA 93% (87%–99%) and ruptured MAAA 74% (62%–86%), P=0.003. Causes of death are shown in Table 3. Of 16 patients with an unknown cause of death, 60% survived >1 year after surgery and 30% survived 5 years.
Overall, infection-related complications developed in 28 patients (21%), of which 13 were fatal (46% of those with an infection-related complication, which constitute 10% of the entire MAAA-treated population) (Table 4). Seventeen of these patients (61%) had at least 1 positive blood culture, in comparison with 69 (78%) of those without infection-related complication, P=0.544. Among those with positive blood culture, no associations could be found between specific bacteria species and risk of infection-related complication. Median antibiotic treatment time, both intravenous and oral, in this cohort with infection-related complications was 16 weeks (range, 0–144). Fifteen patients developed an infection-related complication during antibiotic treatment, and 13 patients developed an infection-related complication after antibiotics were discontinued. Seventy-five per cent of all infection-related complications occurred within the first year after surgery. Median time until infection-related complication was 3 months (range, 0.1–114).
Comparison of OR and EVAR
Demographics and culture results of patients treated with OR and EVAR are presented in Table 1 and online-only Data Supplement Table I. The EVAR cohort had a lower proportion of patients with preoperative hypotension and a higher proportion of rapid aortic expansions, whereas other characteristics did not differ. Kaplan-Meier analysis of survival after OR and EVAR demonstrated that EVAR was associated with better survival at 30 days (OR 89% versus EVAR 99%, P<0.001) and at 3 months (OR 74% versus EVAR 96%, P<0.001) with a similar trend at 1 year (OR 73% versus EVAR 84%, P=0.054). There was no difference in survival at 5 years (OR 60%, EVAR 58%, P=0.771) and 10 years (OR 39%, EVAR 41%, P=0.821). Sixteen of 17 deaths (94%) within 3 months after surgery occurred in the OR group. A propensity score–weighted analysis, including preoperative patient and aneurysm characteristics, bacteriology, and operation year, as well, in the scoring system, confirmed the early better survival associated with EVAR (Figure 3). To further assess the possible effect of patient selection on outcome, separate survival analyses were performed comparing outcome of OR versus EVAR in patients with intact aneurysms, rupture, preoperative hypotension, and no history of hypotension. EVAR was associated with better short-term survival at 90 days in all subgroups, with no difference in survival remaining at 5 years (online-only Data Supplement Figure I). The observed difference in short-term survival in patients with preoperative hypotension (OR n=15, EVAR n=7) did not reach statistical significance. To adjust for time, 2 additional survival analyses were performed comparing OR versus EVAR restricted to the period when both surgical approaches were being used, 2001 to 2014. These analyses did not alter the early survival difference between OR and EVAR (online-only Data Supplement Figure II).
There was no difference between OR and EVAR in overall infection-related complications: 18% versus 24%, P=0.439, or fatal infection-related complications, 8% versus 11%, P=0.517 (Table 4). There were 4 cases of postoperative aortoenteric fistulas (AEFs) after OR and EVAR, respectively. In those who developed AEF after OR: 3 of 4 had at least 1 positive blood culture, and 2 of the 4 quit postoperative antibiotic treatment after <2 months. In those who developed AEFs after EVAR, 3 of the 4 had at least 1 positive blood culture and quit their antibiotic treatment after <6 weeks. In a competing risk analysis, OR was associated with an increased risk of infection-related death at 3 months (OR 11.3%, EVAR 0%, P=0.002), but not thereafter (Figure 4).
Reoperations were performed in 30 patients (23%; 21% after OR and 24% after EVAR, P=0.650) (Table 2). Four patients (6%) treated with EVAR were converted to OR because of stentgraft infection (n=1) after 6 months, secondary AEF (n=2) after 30 and 114 months, and continuing sepsis (n=1) within 1 week of surgery. All 4 recovered well from these reoperations. One patient developed a secondary AEF 9.5 years after EVAR of an infrarenal MAAA, and was then treated with an open approach and lived another 18 months before death of unknown, but considered natural, cause, at the age of 78 years.
In a multivariable logistic regression analysis, OR was associated with a 7-fold increase in odds ratio for 3 months mortality (Tables 5 and 6). In a multivariable Cox regression analysis of 5-year mortality, increased age, rupture, and suprarenal aneurysm location were associated with an increased hazard ratio for death, whereas postoperative antibiotic treatment >6 months had a hazard ratio <1.0 (Tables 5 and 6).
This nationwide study demonstrates a paradigm shift in treatment of MAAAs. Although open surgery is often reported as the gold standard for treatment of MAAA, the current report demonstrates that EVAR is now the most prevalent surgical technique in Sweden, with superior short-term outcome and comparable long-term results in comparison with OR.
Because of its rarity and disease heterogeneity, there is a striking paucity of evidence for the treatment of MAAs. In this study, only patients with MAAAs were included to increase homogeneity in the interpretation of the results. Thus, the present study offers a unique opportunity to compare outcome after OR and EVAR in a relatively homogenous cohort of patients with MAAAs, in a population-based setting (resulting in a lower risk of selection bias) with prospectively collected long-term survival data without loss to follow-up. EVAR as treatment for MAAA has previously been regarded with skepticism. Major concerns regarding not resecting the infected tissue and the risk of recurrent/persistent infection have naturally been raised. The results of this study do not reaffirm that skepticism. On the contrary, this report confirms the positive results of previous studies on EVAR for MAAAs.11–15,18
The observed MAAA-repair incidence (0.6% of all treated AAAs) is in strict accordance with previous analysis.2 The incidence of MAAA was increasing throughout the study period. This could potentially be a result of more frequent use of EVAR, enabling treatment of patients previously considered unfit for surgery, and higher rate of disease detection because of more frequent use of computed tomography imaging.
The overall survival in this cohort is comparable to previous reports.22–25 Almost all early deaths (16/17) in this cohort occurred in the OR group. In a subgroup analysis, short-term survival was superior for EVAR in comparison with OR both in patients with ruptured MAAAs and those with intact MAAAs, as well. Previous studies have indicated that the presence of systemic inflammatory response syndrome is a major predictor of perioperative mortality in patients undergoing OR for MAAA.8,26 Although systemic inflammatory response syndrome criteria could not be applied to the current cohort because of the lack of data on heart and respiratory rate, the presence of preoperative shock and sepsis were not significant predictors of short- or long-term mortality in the multivariable analysis. Only 4 cases (6%) treated with endovascular approach were converted to OR because of severe persisting or recurrent infection. In these cases, EVAR worked as a bridge to later definitive surgery. Recurrent infection-related complications occurred in one-fifth of the patients in the present study, and half of these were fatal, with equal occurrence after OR and EVAR. The rate of late graft infections and AEF (4.5%, Table 4) was in line with previous publications,9,25 with no difference between OR and EVAR. Prolonged pre- and postoperative antibiotic treatment, along with adjunctive drainage of abscesses, is key in avoiding recurrent infections, and long-term postoperative antibiotic treatment was a predictor of improved 5-year outcome. Vigilant surveillance, with regular assessment of laboratory markers for inflammation and radiological follow-up, is of paramount importance to detect complications in a timely manner and to achieve durable results.
The best results after surgical repair of MAAA (OR and EVAR) are suggested to be attained when antibiotics are administered until clinical manifestations of the infection are controlled before surgical intervention.4,17,25 These results may be affected by selection bias, however. Furthermore, such a strategy may be risky because of the high risk of rupture. In this cohort, rupture and suprarenal aneurysm location were significant risk factors for death within 5 years, findings supported by previous publications.9,24,27,28
Blood culture results were positive in 66%, dominated by Streptococcusspecies, Staphylococcus aureus, and Salmonella species. This provides support for previous recommendations of initiating empirical antimicrobial therapy with agents effective against Gram-positive cocci and Gram-negative rods in cases of suspected MAAA.12,29
Although this study, to our knowledge, includes the largest cohort of MAAs reported to date, the cohort is still limited in size, which affects the possibilities for performance of repeated multivariable analyses. The Swedvasc registry only registers patients who are treated surgically, and does not contain data on those treated conservatively. The duration of preoperative antibiotic treatment could not be reliably extracted from the medical charts and is therefore not included in this analysis. The definition of an MAAA used in this study is in accordance with the existing literature. It may also be defined as an aneurysm with proven bacterial infection in the aortic wall,23,25 however, which creates an inherent limitation in studies of this disease, especially when treated endovascularly where bacterial culture from the aortic wall cannot be obtained without risk. MAAA patients often receive broad-spectrum antibiotics early, which partly explains the observed rate of positive culture (66%), which is still in line with the literature.7,9,30 Because the span of this study is >20 years, the results of surgical management should also be tempered by progress in intensive care management and antibiotic treatment. In register-based studies, direct comparison of outcome on the basis of surgical technique may be affected by selection bias. The early survival benefit of EVAR in comparison with OR for MAAA, however, was persistent in the propensity score–weighted analysis and multivariable analysis correcting for patient-related factors and operation year, and in analyses of subgroups, as well. The current report does not allow clear recommendations regarding which patients with MAAA to select for OR versus EVAR, but does support that EVAR may be a durable treatment option. The possibility to offer a minimally invasive surgical intervention is especially appealing in patients with high age, with immunosuppressive condition or treatment, and in those with severe sepsis or hemorrhagic shock, and may increase the possibility to treat patients otherwise regarded as unfit for open surgical repair.
Although the role of EVAR for MAAA has been questioned because of the perceived risk of reinfection, the present study indicates that EVAR for MAAA is associated with better short-term survival in comparison with OR, and comparable long-term results in terms of survival and infection-related complications or reinterventions. In Sweden, EVAR has been the primary surgical technique used for MAAAs in recent years, and data suggest that more patients are being offered treatment after the introduction of EVAR. On the basis of the results of the present cohort study, it seems justified to regard EVAR as an acceptable alternative to traditional OR for the treatment of MAAAs.
Swedish collaborator group for mycotic abdominal aortic aneurysms: Department of Vascular Surgery, Karolinska Hospital, Stockholm– David Lindström, Rebecka Hultgren, Carl-Magnus Wahlgren; Unit of Vascular Surgery, Department of Hybrid and Interventional Surgery, Sahlgrenska University Hospital, Gothenburg– Håkan Roos, Marcus Langenskiöld; Vascular Centre, Skåne University Hospital, Malmö– Timothy Resch, Roberta Vaccarino; Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Vascular Surgery, Örebro University Hospital, Örebro– Linda Bilos, Artai Pirouzram; Department of Surgical and Perioperative Sciences, Surgery, Umeå University Hospital, Umeå– Conny Arnerlöv; Department of Surgery, Central Hospital Karlstad, Karlstad– Gabor Simo; Department of Surgery, Falu Hospital, Falun– Mats Svensson; Department of Surgery, Helsingborg Hospital, Helsingborg– Johan Magnusson; Department of Surgery, Jönköping Hospital, Jönköping– Håkan Astrand; Department of Surgery, Mälar Hospital, Eskilstuna– Nils-Peter Gilgen; Department of Surgery, NU-Hospitalgroup, Trollhättan/Uddevalla– Stefan Mellander; Department of Surgery, Östersunds Hospital, Östersund– David Korman; Department of Surgery, Gävle Hospital, Gävle– Khatereh Djavani-Gidlund; Department of Surgery, Sunderby Hospital, Sunderbyn– Markus Palm; Department of Thoracic and Vascular Surgery, and Department of Medical and Health Sciences, Linköping University, Linköping– Mårten Huss; Department of Vascular Surgery, Västerås Hospital, Västerås– Adam Bertszel; Department of Surgery, Hudiksvall Hospital, Hudiksvall–Michael Docter; Department of Surgery, Borås Hospital, Borås– Christer Drott; Department of Surgery, Kalmar Hospital, Kalmar– Andreas Öjersjö; Department of Vascular Surgery, Skaraborg Hospital, Skoevde– Olle Nelzén; Department of Surgery, Kristianstad Hospital, Kristianstad– Tomas Wetterling; Department of Surgery, Regional Hospital Sundsvall, Sundsvall– Ming Chu.
The authors acknowledge Marcus Thuresson, Statisticon, Uppsala, Sweden, for statistical expertise. They also acknowledge the Swedvasc steering committee (Birgitta Sigvant, Katarina Björses, Lena Blomgren, Anna Wigelius, Joakim Nordanstig, Erik Wellander, Joakim Starck) and the collaborating centers for administration of the Swedvasc registry and data collection.
Sources of Funding
Sources of Funding, see page 1831
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.116.024021/-/DC1.
Circulation is available at http://circ.ahajournals.org.
- Received June 16, 2016.
- Accepted October 11, 2016.
- © 2016 American Heart Association, Inc.
- Osler W
- Greenfield LJ
- Bandyk DF
- Sörelius K,
- Mani K,
- Björck M,
- Sedivy P,
- Wahlgren CM,
- Taylor P,
- Clough RE,
- Lyons O,
- Thompson M,
- Brownrigg J,
- Ivancev K,
- Davis M,
- Jenkins MP,
- Jaffer U,
- Bown M,
- Rancic Z,
- Mayer D,
- Brunkwall J,
- Gawenda M,
- Kölbel T,
- Jean-Baptiste E,
- Moll F,
- Berger P,
- Liapis CD,
- Moulakakis KG,
- Langenskiöld M,
- Roos H,
- Larzon T,
- Pirouzram A,
- Wanhainen A
- Jia X,
- Dong YF,
- Liu XP,
- Xiong J,
- Zhang HP,
- Guo W
- 21.↵The R Project for Statistical Computing. http://www.R-project.org.Accessed November 15, 2016.
What Is New?
This nationwide study of treatment of mycotic abdominal aortic aneurysms in Sweden 1994 to 2014 encompasses the largest cohort of mycotic abdominal aortic aneurysms reported to date.
The study shows a paradigm shift in treatment of mycotic abdominal aortic aneurysms in Sweden, with the majority of repairs being performed with endovascular technique (endovascular aneurysm repair) in recent years.
It demonstrates that endovascular aneurysm repair is associated with improved short-term survival in comparison with open repair, without higher associated incidence of infection-related complications or reoperations.
What Are the Clinical Implications?
Endovascular aneurysm repair is a durable surgical option for treatment of mycotic abdominal aortic aneurysms, and is an acceptable alternative to open repair.
With access to a minimally invasive technique for treatment of this fatal disease, more elderly and frail patients can potentially be offered surgical intervention.