Latest / European Society for Vascular Surgery / Vascular Graft and Endograft Infection Workshop with B. Saleem & X. Berard

Transcript

Vascular Graft and Endograft Infection Workshop with B. Saleem & X. Berard · European Society for Vascular Surgery

• 0:03
  Hello and welcome back to the ESVS podcast. Today's
• 0:07
  episode is recorded live at the ESVS workshop
• 0:10
  on vascular graft and endograft infection in
• 0:13
  Groningen. A two -day course focused entirely
• 0:16
  on one of the most challenging problems in vascular
• 0:19
  surgery. The program combines expert lectures,
• 0:22
  case -based discussion and hands -on sessions
• 0:24
  with a strong emphasis on multidisciplinary decision
• 0:27
  -making. Over the next two days we'll have short
• 0:30
  conversations with the faculty and participants
• 0:33
  about what they see as the key challenges, where
• 0:36
  uncertainty remains and what practical lessons
• 0:39
  they are taking home. The workshop is great and
• 0:42
  there is a lot of tips and tricks and a lot of
• 0:45
  practice. So we just finished the first session
• 0:57
  of the workshop and it's already clear that this
• 1:00
  is going to be a really high value meeting. The
• 1:03
  opening session brought together a great combination
• 1:05
  of expert insights, practical perspectives and
• 1:08
  really engaging discussions. I'm very pleased
• 1:11
  to be joined by two key figures behind this workshop.
• 1:15
  Professor Ben Saleem, one of the driving forces
• 1:18
  behind the event and Professor Xavier Berard.
• 1:22
  Thank you both for taking the time to speak with
• 1:24
  us. Thank you. Thank you very much for the opportunity.
• 1:27
  My name is Ben Salim. I'm a vascular surgeon
• 1:29
  from the University Medical Center of Groningen
• 1:31
  in the Netherlands. It's a great pleasure to
• 1:34
  welcome you here in Groningen for the ESVS Vascular
• 1:38
  Craft and Endocraft Infections Workshop. This
• 1:40
  is the first time we're organizing this workshop.
• 1:42
  The key message is that it's a devastating diagnosis.
• 1:45
  It's not easy to treat, especially if you try
• 1:49
  to do it by your own. So a multidisciplinary
• 1:51
  meeting and approach to this diagnosis is very
• 1:55
  important. very important. And from your perspective,
• 1:57
  what actually makes graft infections so difficult
• 1:59
  to diagnose? Well, that's a really good question,
• 2:01
  because until 20 years ago, we thought that there
• 2:05
  were no vascular graft infections. The difficulty
• 2:08
  about it is if you don't know it, you don't see
• 2:11
  it. So in our case is that if you suspect vascular
• 2:15
  graft infections, it's very important to do the
• 2:19
  right diagnose to diagnose it. That doesn't mean
• 2:22
  that you have to treat the patients because it's
• 2:25
  not like we are trying to diagnose everyone with
• 2:28
  a low -grade infection just to treat them. It's
• 2:30
  only we want to understand more the disease and
• 2:36
  how to make a better quality of life for the
• 2:40
  patients. So in some cases, when you had high
• 2:46
  -grade infections or artridulinal fistula or
• 2:50
  Crohn infection, then it's clear to diagnose,
• 2:53
  and that's not so difficult. The difficulty is
• 2:56
  when you have a patient with a graft infection
• 2:59
  and only some kind of symptoms like elevated
• 3:04
  CRP, general meleesis, and... We don't understand
• 3:07
  what the real reason is. So in my opinion, I
• 3:11
  always tell my colleagues, it's graft infection
• 3:13
  until otherwise it's proven. And then the difficulty
• 3:18
  is, what should we do? We all know that the golden
• 3:22
  standard is by removing the graft and send it
• 3:27
  for microbiology. But of course, then you will
• 3:29
  be treating the patient before the diagnosis.
• 3:31
  So the important thing is to have to collect
• 3:36
  some material around the graft to be sure that
• 3:40
  it's graft infection and also to avoid operating
• 3:43
  patients with false positive imaging. So about
• 3:49
  the imaging, what is the role of PET imaging
• 3:51
  in current practice? When do you decide to use
• 3:54
  it and what can you realistically expect to gain
• 3:56
  from it? In my opinion, the gold standard is
• 4:00
  still the CT angio. However, that doesn't rule
• 4:03
  out a vascular graft infection. So we start with
• 4:07
  the CT angio and if that is negative, but the
• 4:10
  suspicion of vascular graft infections is high.
• 4:13
  We always do a PET -CT angio. With a PET -CT,
• 4:17
  you get more information about the FDG activity.
• 4:21
  So it helps you not only to be sure about the
• 4:24
  diagnosis, but it also helps you to know if there
• 4:28
  is any other infection going on around the graft
• 4:32
  or somewhere else, for example. It is important
• 4:36
  to have a look at the PET scan together with
• 4:39
  the nuclear medicine. Because for us, it's not
• 4:43
  easy to understand what the FTG activity is.
• 4:45
  You should look up for homogeneity and heterogeneity
• 4:49
  FTG activity. However, for the nuclear medicine,
• 4:52
  it's also not easy to judge the PET scan if they
• 4:54
  don't have information enough about the vascular
• 4:57
  graft. So if they don't know it's an R2 -BiFem
• 5:00
  or it's a Fem -Fem crossover, they don't know
• 5:02
  where to look. I have one example of an R2 -BiFem
• 5:07
  PET scan, which was... implanted because of occluded
• 5:13
  disease. So in that case, anatomically, the graft
• 5:16
  will be in front of the aorta, right? How we
• 5:19
  always implant it. And this patient had a PET
• 5:23
  scan and it was judged as an aortitis because
• 5:29
  the nuclear medicine thought, well, look, the
• 5:31
  FDG activity is in front of the aorta, not the
• 5:35
  aorta itself. So based on your work on the upcoming
• 5:39
  guidelines, do you think they will change the
• 5:41
  way we manage these patients in daily practice?
• 5:43
  Yes, so it's good to mention that we are working
• 5:46
  on an update, so the second version of vascular
• 5:49
  graft infection. Hopefully we will publish it
• 5:51
  at the end of the year. It isn't easy to write
• 5:55
  a guideline about vascular graft infection because
• 5:57
  there are not so much studies about vascular
• 6:01
  graft infection. And the population, what we
• 6:05
  are studying, is heterogenic. So that's why the
• 6:08
  recommendations are mostly based on expert opinion.
• 6:13
  However, if you look at the previous guideline,
• 6:17
  we also had nuclear medicine in it, because we
• 6:21
  think it's important to approach this diagnosed
• 6:23
  multidisciplinary. And we now also have internal
• 6:30
  medicine infectiologists and microbiologists
• 6:32
  who help us to understand what kind of antibiotic
• 6:36
  we should give if we go for suppressive therapy
• 6:40
  or a complete cure of vascular graft infection.
• 6:45
  So that will be an important issue for upcoming
• 6:50
  guidelines. so about that where was the main
• 6:53
  gaps in knowledge where should future studies
• 6:56
  go well we have a lot what we have to do i think
• 7:00
  mainly because we all struggle with autologic
• 7:07
  fame they are not always available that takes
• 7:09
  a lot of time and it's not always possible in
• 7:13
  unfit patients So, of course, unfit patients,
• 7:18
  you can also treat them with suppressive therapy,
• 7:20
  but we all know that the long -term results and
• 7:23
  the mortality of that is not good enough as treating
• 7:28
  them with complete explantation of the graft
• 7:31
  and autologic reconstruction. So the main thing
• 7:36
  what we have to find out in the future is what
• 7:39
  kind of best second choice graft can we use?
• 7:43
  Is it the bovine tubes, bovine patches, bifurcation
• 7:48
  graft? Or is it the silver graft? So more research
• 7:53
  is needed for that to rule out the long -term
• 7:57
  outcome and reinfection rates of that. Thank
• 8:01
  you. And one last question. When a patient comes
• 8:04
  to your hospital and you suspect a graft infection,
• 8:07
  what's your go -to approach? That's a really
• 8:11
  good question. The GOAT approach is, we have
• 8:16
  a protocol for that. We also publish that protocol
• 8:19
  online, so it's available. What we mainly do
• 8:24
  is, of course, collect all the information you
• 8:26
  have on the patients. You have to rule out false
• 8:29
  positive vascular graft infections. You don't
• 8:31
  want to treat... the patient unnecessary. So
• 8:35
  after collecting all information, do a multidisciplinary
• 8:41
  meeting. After a CT scan, PET scan, sometimes
• 8:46
  we do a CT -guided puncture, drainage for microbiology
• 8:51
  or sometimes also pathology to be sure that it's
• 8:54
  not an aortitis. So try to rule out everything
• 9:00
  and then find if there is autologic feign available.
• 9:05
  If not, they will go for the best second choice,
• 9:08
  which is bovine or a silver craft. Thank you
• 9:12
  so much. Thank you for joining us. Well, thank
• 9:14
  you very much for the opportunity. All right.
• 9:16
  That was a great conversation with Professor
• 9:19
  Ben Salim. We're now moving to a different spot
• 9:22
  here at the workshop and I'm very happy to welcome
• 9:25
  our next guest. Joining me is Professor Javier
• 9:28
  Berard. So you focus a lot on open surgery and
• 9:30
  graft explantation. When do you decide to explant
• 9:33
  a graft? What are the key factors you have to
• 9:35
  consider? And can you walk us through how you
• 9:37
  plan such a case? So it's always a big thing
• 9:42
  to remove a stand graft from a patient. It's
• 9:45
  a huge surgery for patients that have been treated
• 9:47
  minimally before. So in my practice, the main
• 9:51
  indication is infection. So this is the main
• 9:54
  reason why we expand the stent graft. In some
• 9:57
  minor situations, we have also to expand them
• 10:00
  for androlysis reasons. But in that situation,
• 10:03
  the majority of androlysis can be treated under
• 10:06
  in our center. So rare occasion for androlysis
• 10:09
  to expand the patient. So this is huge surgery.
• 10:12
  So the key factors. for planning are super strong
• 10:18
  analysis of the pre -op CT angio to detect exactly
• 10:22
  the anatomy to define in advance the clamping
• 10:25
  zone to have a strategy for the organ protection
• 10:29
  and then you need a really good team together
• 10:35
  with you including of course the anesthesiology
• 10:37
  during the surgery but also the ICU team for
• 10:40
  the post -operative course so a lot of planning
• 10:43
  in advance and a textbook execution in the OR.
• 10:46
  What do you think about the prehabilitation of
• 10:49
  the patient? It's really a game changer because
• 10:51
  you improve the outcome for the patient but in
• 10:55
  the setting of the infection it can be a little
• 10:57
  bit tricky because you postpone the surgery if
• 11:00
  you want to really gain something before the
• 11:03
  surgery for the patient so it's a balance between
• 11:05
  optimization of the patient but not delay too
• 11:08
  much especially if it's an infected case. So,
• 11:12
  what are the main pitfalls during graft explantation
• 11:14
  and how to avoid them? So, the first pitfall
• 11:18
  is the lack of preparation. So, you need to exactly
• 11:21
  know what is the stand graft that you need to
• 11:25
  remove. If there is infrarotinal fixation, suprarotinal
• 11:28
  fixation, if you need to remove everything or
• 11:32
  if you go for partial explant because it's a
• 11:34
  tough case like a beaver or a fever and finally...
• 11:38
  PET CT rule out a complete infection, you just
• 11:40
  have to remove some parts. So first is that.
• 11:43
  Then during the surgery you need to make everything
• 11:48
  smooth and you need to place the anesthesiologist
• 11:51
  10 minutes in advance to what will happen during
• 11:54
  the surgery. So it's a lot of explanation during
• 11:59
  the surgery for the different steps to be sure
• 12:02
  that everything is prepared and to face any problem.
• 12:06
  for example you can have a massive bleeding from
• 12:08
  a tearing from the cava in that situation you
• 12:12
  need to just put a finger see around you who
• 12:15
  is around with you call the anesthesiologist
• 12:18
  if he's outside the room at the moment and to
• 12:21
  give him the time to make the patient in good
• 12:23
  condition so it's not the time where you will
• 12:25
  try to fix the problem because you will make
• 12:29
  the patient bleed more you just give time to
• 12:31
  the others to make the patient Excellent, and
• 12:34
  then you will repair the problem. So looking
• 12:36
  ahead, what should we expect in the future with
• 12:39
  endovascular techniques advancing rapidly and
• 12:41
  fewer surgeons gaining extensive open experience?
• 12:43
  Do you think we need to rethink how we train
• 12:46
  surgeons to maintain these complex open skills?
• 12:49
  This is a major challenge. I think in my center
• 12:52
  we still propose a lot, so I think my trainees
• 12:54
  are not really exposed to that problem. But when
• 12:57
  I go for several meetings across the world, I
• 13:00
  feel a great fear in the trainee to not be trained
• 13:03
  properly in open surgery anymore and to be forced
• 13:07
  to do endo in some situation where maybe an open
• 13:09
  surgery could be better. So the only way in my
• 13:13
  view to overcome this is to offer to the trainee
• 13:19
  the possibility to access workshops like we have
• 13:22
  done during this two days workshop for graft
• 13:25
  infection. to offer short visiting, could be
• 13:29
  a week, could be a month. I think it's easy today
• 13:33
  to travel much easier than it was in my training
• 13:36
  years for me. And we should also look for new
• 13:40
  disruptive technology like Google Glass or stuff
• 13:43
  like this to make it easy for the trainees to
• 13:47
  learn from their home. directly from other ORs.
• 13:51
  So I would say that probably this last thing
• 13:54
  is the most exciting thing that we need to promote.
• 13:57
  And about the current guidelines, what do you
• 13:59
  think they will bring in the future? The new
• 14:02
  guidelines will provide more accurate guidance.
• 14:06
  So for example, the new guidelines will be more
• 14:09
  precise in what type of graph we will use to
• 14:13
  guide us. they will be more focusing on conservative
• 14:17
  treatment too because it's not only removal the
• 14:20
  material sometimes it's not a good idea and to
• 14:23
  also define what is the mdt attitude and what
• 14:27
  should be the ideal mdt group thank you thank
• 14:30
  you for joining us thank you what a pleasure
• 14:33
  we just wrap up two fantastic conversations So
• 14:39
  please join me as we move to the workshop floor
• 14:42
  and talk with our trainees in the middle of their
• 14:44
  hands -on session and workshop experience. Let's
• 14:47
  check on them. We are joining some attendees
• 14:52
  and we are going to ask them about their work
• 14:55
  during the course. So guys, what are you doing
• 14:57
  now? Right now we perform an explant of a silver
• 15:02
  graft. aortic femoral infected bypass. We just
• 15:08
  finished the explant and now we are trying to
• 15:11
  do configuration, a taper configuration for an
• 15:15
  aortic tube with a pericardic patch. I can see
• 15:19
  two layers of sutures. Is that standard approach?
• 15:22
  Yes. They first recommend a U -shaped suture.
• 15:31
  And then you do a reinforcement suture after
• 15:35
  you're done. Who did the first line? So, hello
• 15:38
  everyone. I see you are working on something.
• 15:41
  Can you tell me what are you doing now? We are
• 15:45
  trying to create a replacement for the patient's
• 15:47
  aorta. And what are you using for that? We are
• 15:49
  using the bovine patch. We are going to use it
• 15:52
  to reconstruct both the main body of the aorta
• 15:55
  and the... And hopefully we get the best. Now,
• 15:59
  the reason we are doing this is because the patient
• 16:02
  previously had an open replacement of his AAA,
• 16:06
  of his aortic abdominal aneurysm. That we did
• 16:11
  yesterday. Yes. Unfortunately, this was the quickest
• 16:14
  infection ever seen. I think you did it. Yes,
• 16:18
  it's my fault. Quickest infection ever seen.
• 16:21
  Thank you. I'm going to go. and ask someone else
• 16:25
  about not mine complication. Borelli, what do
• 16:28
  you think about the course? What do you think
• 16:30
  about the workshop? I think it's an amazing experience
• 16:34
  because we have... be able to know the perspective
• 16:38
  of the microbiologist infectious disease department
• 16:42
  also the colleagues from nuclear medicine that
• 16:47
  they told us how is the correct interpretation
• 16:50
  of patients with any suspicion of infection graft
• 16:54
  and i think it was amazing because we have been
• 16:58
  able to fusion the The theoretical part and also
• 17:02
  the hands -on in some practical models and also
• 17:08
  with the category part. Thank you. What do you
• 17:11
  think, Ioannis? Well, you know, the French guys,
• 17:15
  once again, they delivered. Berardo is excellent.
• 17:20
  Hello, can you introduce yourself and tell us
• 17:22
  a little bit more about this workshop? I'm Clark
• 17:26
  Zebrax, professor of vascular surgery at Groningen
• 17:30
  University Hospital. And we have a vascular graft
• 17:35
  infection ESVS workshop right now and it's very
• 17:38
  well attended and I think very well appreciated
• 17:42
  by the attendants also. And it's a mixture of
• 17:45
  talks, plastic models and also cadavers in which
• 17:50
  we try to teach everyone how to deal with vascular
• 17:55
  graft infections. Thank you so much. And all
• 17:59
  of that in this perfect, beautiful city of Groningen.
• 18:03
  Exactly, because Groningen is a very vibrant
• 18:06
  city. It has a lot of students and actually one
• 18:10
  quarter of the inhabitants is student. And that
• 18:14
  means that the bars and restaurants are open
• 18:16
  all night. Thank you so much. All right. Thank
• 18:18
  you for joining us for this special episode straight
• 18:21
  from the workshop floor. We've heard from both
• 18:22
  the experts and the trainees. And one thing is
• 18:26
  clear. Education, collaboration, and hands -on
• 18:28
  experience remain at the heart of vascular surgery.
• 18:31
  See you at the next episode.