Treatment and outcomes of aortic endograft infection

Smeds, Matthew R.; Duncan, Audra A.; Harlander-Locke, Michael P.; Lawrence, Peter F.; Lyden, Sean P.; Fatima, Javariah; Eskandari, Mark K.; Steenberge, Sean P.; Tomita, Tadaki M.; Morasch, Mark D.; Jim, Jeffrey; Lyons, Lewis C.; Charlton-Ouw, Kristofer M.; Mushtaq, Harith H.; Leake, Samuel S.; Motaganahalli, Raghu L.; Nelson, Peter R.; Parkerson, Godfrey R.; Shalhub, Sherene; Bove, P; Modrall, Gregory; Davila, Victor J.; Money, Samuel R.; Hedayati, Nasim; Abou-Zamzam, Ahmed M.; Abularrage, Christopher J.; Wittgen, Catherine M.

doi:10.1016/j.jvs.2015.08.113

Cited by 202 publications

(191 citation statements)

References 20 publications

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“…Clinically, patients present with constitutional symptoms including pain, fever and chills, which may prompt suspicion for postoperative infection (49,50). Aortic graft infections occurring more than 3 months after repair are initially evaluated with CT or MRI, which may reveal ectopic gas, peri-graft inflammation and fluid, thickening of adjacent bowel, and pseudoaneurysm formation at the graft anastomosis (51).…”

Section: Diagnosismentioning

confidence: 99%

Inflammatory and infectious aortic diseases

Deipolyi

Czaplicki

Öklü

2018

Cardiovasc. Diagn. Ther.

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Aortitis is aortic inflammation, which can be due to inflammatory or infectious diseases. Left undiagnosed, aortitis can lead to aneurysm formation and rupture, in addition to ischemic compromise of major organs. Infectious aortic diseases include mycotic aneurysm and graft infection; the most common inflammatory diseases are Takayasu's and giant cell arteritis. We review the epidemiology, etiology, presentation and diagnosis, and treatment of these entities. S62infectious extravascular source adjacent the arterial wall (16,17). Bacteria may seed the arterial wall injury either from bacteremia or septic emboli (18). Typically, infection initiates in a nidus such as in an ulcerated atherosclerotic plaque or in the vasa vasorum (12). The vasa vasorum is thought to be key in the pathogenesis of MA formation; due to its small lumen size and slower flow, it is more susceptible to bacterial colonization (19,20). The vasa vasorum is more pronounced in larger arteries, which may explain why the aorta is the most common site of MA formation. DiagnosisEarly diagnosis and rapid triage for intervention is key to reducing mortality from MA (21,22). However, diagnosis is challenging given the low prevalence and nonspecific symptoms. Clinical signs may include fever and laboratory abnormalities including elevated erythrocyte sedimentation rate and leukocytosis (23). Bacteremia is common, though cultures may be negative, particularly after antibiotics have been given. Symptoms include pain or a pulsatile mass (23). In the setting of pre-existing endocarditis, prior invasive procedures, intravenous drug use or immunocompromise should increase suspicion (8,24).Non-invasive cross-sectional imaging is essential in the diagnosis of MA. Computed tomography angiography (CTA) has arisen as the imaging modality of choice owing to its excellent resolution allowing for three-dimensional reconstruction and its rapid acquisition; magnetic resonance imaging (MRI) may also be used (25)(26)(27). Certain features may distinguish MA from non-infected aneurysms, including serial imaging which may reveal rapid progression typical of infected aneurysms. Other characteristic features include contrast-enhancement and a saccular outpouching configuration, whereas non-infected atherosclerotic aneurysms tend to be fusiform (28). Saccular configuration may also suggest imminent rupture, alerting the need for further urgent diagnostic workup. Other features include irregularity of the arterial wall and peri-aortic gas, edema, mass or stranding (28). MAs also tend to have higher uptake on FDG-PET imaging of 4.5 SUV max or more compared with non-infected aneurysms (29). FDG-PET boasts high sensitivity and its potentially high false-positive rate can be improved with simultaneous CT. Treatment and prognosisDue to its elusive presentation, MA is often difficult to treat because of delayed diagnosis. Rapid diagnosis and treatment is key, as aortic MA is associated with 15-50% mortality (7)(8)(9)24). No randomized trials are available to guide manage...

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Section: Diagnosismentioning

confidence: 99%

Inflammatory and infectious aortic diseases

Deipolyi

Czaplicki

Öklü

2018

Cardiovasc. Diagn. Ther.

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“…5,11 In contrast to other microbiological diagnostic criteria, positive blood cultures were considered minor criteria as they do not provide direct, site-specific evidence of AGI, and their significance depends upon how confidently alternative sources can be excluded. The use of blood inflammatory markers as corroborative evidence for AGI was proposed, but these were also classed as minor criteria because they are nonspecific and typically elevated in the immediate postoperative period and multiple other concurrent, noninfective conditions.…”

Section: Laboratory Criteriamentioning

confidence: 99%

“…6e10 Conversely, and often despite prolonged antimicrobial treatment, mortality within 2 years can approach 100% if an infected endograft is left in situ. 6,11 The diagnosis and management of AGI is highly complex, clinical manifestations are protean, and there is no "goldstandard" diagnostic test. 3,5 In the existing literature, radiological data are mostly descriptive, microbiology details are brief or incomplete, and there have been no well designed trials of the optimum antimicrobial agent(s), route of administration, and treatment duration.…”

Section: Introductionmentioning

confidence: 99%

Diagnosis of Aortic Graft Infection: A Case Definition by the Management of Aortic Graft Infection Collaboration (MAGIC)

Lyons¹,

Baguneid²,

Barwick³

et al. 2017

Journal of Vascular Surgery

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WHAT THIS PAPER ADDSThere is no universally accepted aortic graft infection case definition and clinical approaches to this complex condition differ widely with variable outcomes. Here, the Management of Aortic Graft Infection Collaboration (MAGIC), involving clinicians from several English hospital National Health Service Trusts with large vascular services, propose a formal case definition, derived by a process of multidisciplinary, expert consensus. The definition is readily applied in routine practice and aids early recognition. Importantly and towards development of evidence-based clinical guidelines that are presently lacking, it provides a consistent diagnostic standard, essential for clinical trial design and meaningful comparison between diagnostic and therapeutic strategies.Objective/Background: The management of aortic graft infection (AGI) is highly complex and in the absence of a universally accepted case definition and evidence-based guidelines, clinical approaches and outcomes vary widely. The objective was to define precise criteria for diagnosing AGI. Methods: A process of expert review and consensus, involving formal collaboration between vascular surgeons, infection specialists, and radiologists from several English National Health Service hospital Trusts with large vascular services (Management of Aortic Graft Infection Collaboration [MAGIC]), produced the definition. Results: Diagnostic criteria from three categories were classified as major or minor. It is proposed that AGI should be suspected if a single major criterion or two or more minor criteria from different categories are present. AGI is diagnosed if there is one major plus any criterion (major or minor) from another category. (i) Clinical/surgical major criteria comprise intraoperative identification of pus around a graft and situations where direct communication between the prosthesis and a nonsterile site exists, including fistulae, exposed grafts in open wounds, and deployment of an endovascular stentgraft into an infected field (e.g., mycotic aneurysm); minor criteria are localized AGI features or fever 38 C, where AGI is the most likely cause. (ii) Radiological major criteria comprise increasing perigraft gas volume on serial computed tomography (CT) imaging or perigraft gas or fluid ( 7 weeks and 3 months, respectively) postimplantation; minor criteria include other CT features or evidence from alternative imaging techniques. (iii) Laboratory major criteria comprise isolation of microorganisms from percutaneous aspirates of perigraft fluid, explanted grafts, and other intraoperative specimens; minor criteria are positive blood cultures or elevated inflammatory indices with no alternative source. Conclusion: This AGI definition potentially offers a practical and consistent diagnostic standard, essential for comparing clinical management strategies, trial design, and developing evidence-based guidelines. It requires validation that is planned in a multicenter, clinical service database

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“…Despite its relatively low overall incidence, the absolute numbers of graft infection are rising with a reported graft infection incidence of 0.2 to as high as 6% [1]. Overall morbidity and mortality rates are high, and in cases of patients' readmission due to aortic graft infection, in-hospital mortality can be 18% or higher [2].…”

Section: Dear Sirmentioning

confidence: 99%