Aortitis (inflammation of the aorta) is either infectious or noninfectious [8]. Examples of noninfectious causes are arteritis, vasculitis or sarcoidosis. These conditions usually do not require surgical treatment. Primary aortic infection on the other hand is an infectious aortitis involving bacterial or other organisms. This may lead to an aortic aneurysm, also described as a mycotic aneurysm. Besides antibiotics, extensive surgery is usually necessary as a definitive treatment. Open and endovascular techniques are possible. Options for open repair are in-situ repair with a prosthetic graft (with or without an omental wrap), with an autologous vein or with an allograft. Another option would be excision of the infected aorta with extra-anatomic reconstruction, either in one or two stages.

A retrospective cohort study by Lee et al. [3] compared in situ repair (ISR, n = 13) versus extra-anatomic bypass (EAB, n = 15) in 28 patients with a mycotic aortic aneurysm (see Table 7.2). Neither perioperative mortality, nor amputation was significantly different between the 2 groups. Late complications did differ significantly (0 % in ISR vs. 33 % in EAB). These included graft occlusion, graft infection and ischemia colitis. The overall reoperation rate for graft salvage was 33 %.

Further studies on this topic included only case reports or case series. Amongst these is an article by van Zitteren et al. [9] describing 5 patients who underwent spiral vein reconstruction with limb salvage after 6–67 months of 100 % and no re-infections. An article by Noel et al. [10] studied 56 patients treated with cryopreserved grafts. The overall mortality was 25 %, persistent infection was 9 %, graft occlusion was 9 % and amputation rate was 5 %. Dubois et al. [11] treated 44 patients with ISR or EAB. In-hospital mortality was 18.9 % and 50 % respectively. Finally, a literature review by Lew et al. [12] on antibiotic-impregnated grafts studying 5 case series shows a 30-day mortality of 7–21 % and graft reinfection of 4–22 %.

The highest level of evidence addressing this topic is a systematic review performed by Kan et al. [13]. The authors report the results of a literature review including 48 cases from 22 studies investigating the outcome after endovascular stent grafting for mycotic aortic aneurysms (either abdominal or thoracic). The 30-day survival rate was 89.6 % and the 2-year survival rate was 82.2 %. Persistent infection occurred in 22.9 % of cases and these patients had a 1-year survival rate of only 39.0 %. In a multivariate logistic regression analysis, rupture of the aneurysm and fever at the time of the operation were the only two independent predictors of persistent infection after EVAR. Additional procedures were performed in 37.1 %, including antibiotics-soaked stents, drainage cannulas and debridement. It is not reported when these procedure were done (at the time of the EVAR or during follow-up). In 45.8 % of patients antibiotics were given more than 1 week before the EVAR. Less than 50 % of the patients received antibiotics postoperatively for more than 4 weeks.

The same authors published their own data on the endovascular treatment of 12 patients with a mycotic aneurysm in 3 hospitals in Taiwan [14]. There was no hospital death in these patients. Three patients received drainage (of whom 1 also underwent a debridement laparotomy) for psoas abscesses. One patient (8.3 %) died after 8 months. Mean follow-up was 2–48 months with no evidence for graft infection. With respect to the antibiotics regimen, their protocol was to start with broad-spectrum antibiotics after blood was drawn for culture followed by endovascular treatment. Bacteria specific intravenous antibiotics were given for at least 4 weeks postoperatively.

A review by Setacci et al. [15] summarizing 6 studies reporting on the role of (T)EVAR in mycotic aneurysms shows a 30-day mortality between 0 and 28.0 % and a 2-year mortality from 16.1 to 45.0 %. Kritpracha et al. [16] reported their results of treating 21 patients with an infected aortic aneurysm using an endovascular stent graft. Five patients presented with an aortoenteric fistula. In this group, the in-hospital mortality was 60 %, whilst in the non-fistula group, this was only 6 %. One conversion was performed in the fistula group. All patients received life-long antibiotics. Sedivy et al. [17] reported their experiences with the endovascular treatment of 32 patients with a mycotic aneurysm. Thirty-day mortality was 19.0 %, 50.0 % after 1 year and 59.4 % after 3 years. All patients received antibiotics prior to the procedure and at least 4 weeks after laboratory results normalized (CRP, white blood count). Salmonella infections were treated indefinitely.

When open repair is chosen, treatment options are similar as for primary aortic infection (in-situ repair with a prosthetic graft, an autologous vein, an allograft or extra-anatomic bypass). Endovascular options are far less studied. (T)EVAR is mostly used in patients with an aortoenteric fistula, often when emergency surgery is necessary.

A meta-analysis done by O’Connor et al. [18] compared EAB, rifampicin-bonded prosthesis (RBP), cryopreserved allografts (CA) and autogenous veins (AV) for the treatment of aortic graft infection in a meta-analysis (Table 7.2). They determined pooled estimates of mean event rates for amputation, conduit failure, reinfections and mortality and found that for all outcomes combined, EAB had the highest event rate (0.16), which was significantly worse compared with all other 3 techniques (p < 0.05). Amputation rate was highest in EAB and AV, conduit failure in EAB, reinfection in RBP and early and late mortality in EAB.

A retrospective cohort study by Batt et al. [19] (not in Table 7.2) compared ISR, including various conduits (venous and non-venous), with EAB in 82 patients. Perioperative mortality was 32 % for ISR and 45 % for EAB (p = NS). Freedom from recurrent infection and survival rates were estimated using the log-rank test. This showed a lower rate of recurrent infection after ISR (p = 0.04) and a higher survival rate after ISR (p = 0.003) compared with EAB.