Latest / European Society for Vascular Surgery / #ESVS2025: Management of Aortic Graft Infections with A. LeJay

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#ESVS2025: Management of Aortic Graft Infections with A. LeJay · European Society for Vascular Surgery

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  Welcome to the ESVS Podcast. This is a live recording
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  from the 2025 ESVS Annual Meeting in Istanbul.
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  I'm Laurence Bertrand and in this episode we're
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  taking on a topic that makes everyone in our
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  field feel uneasy. Aortic stent infections. Rare
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  but devastating and often controversial when
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  it comes to diagnosis, treatment and long -term
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  outcomes. I'm joined by Dr. Anne Lejay, vascular
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  surgeon at the University of Strasbourg, recognized
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  authority in complex aortic disease and infection
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  management. And we are catching her just before
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  her participation in the live debate on this
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  very topic. Thank you for being here. Hi, very
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  happy to be here. Let's start straight with the
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  questions, with the basics. How common are aortic
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  stent infections really? And do you think that
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  the true incidence is maybe under -recognized?
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  Well, incidence is increasing and has been reported
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  up to 5%. But you're completely true. It's probably
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  underreported since underrecognized. Yeah. So
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  what are the typical clinical scenarios where
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  you begin to suspect clinical infection in a
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  patient with aortic endografting? Yes, clinical
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  presentation is highly varied. It can range from
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  mild symptoms to septic shock. However, systemic
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  symptoms such as loss of appetite, unexplained
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  weight loss, lethargy or fever should raise suspicion
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  of infection. So when we come to diagnosis and
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  imaging, it can be a real grey zone. One framework
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  people may know is the MAGIC criteria, the Management
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  of Aortic Graft Infection Collaboration Guidelines.
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  How often do you actually find these criteria
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  useful in day -to -day practice? And do you think
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  we need something more tailored to end graft
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  infections specifically? I don't think we need
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  something more tailored because these criteria
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  are very helpful in clinical practice, either
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  for graft or endograft infection. Just to remind
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  our listeners, MAGIC combines clinical imaging
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  and laboratory findings. The criteria are split
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  into major and minor categories. For example,
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  major criteria include things like persistent
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  paragraphed air or fluid beyond seven weeks after
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  surgery, positive cultures from paragraphed aspirates
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  or direct evidence of infection on imaging. endoscopy.
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  Minor criteria include findings such as fever,
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  elevated inflammatory markers, unexplained bacteremia
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  or suspicious but not definitive imaging changes.
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  According to MAGIC, a diagnosis of graft or endograft
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  infection requires at least one major plus one
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  other criterion. With that in mind, how do you
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  personally approach workup CT, PET -CT, tagged
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  white cell scans, and where do you see their
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  limitations? Yes, the main limitation is to differentiate
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  an infection from a sterile inflammation. So,
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  multiphase CTA is the first -line imaging modality.
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  It's important to correlate data from CTA and
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  nuclear imaging so you can improve the diagnosis
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  accuracy. So PET -CT or white blood cell scan
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  can be used. I think in the early post -operative
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  phase, white blood cell scans is more specific.
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  The problem is it's not always available. So
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  what are you using? I'm using multi -phase CTA,
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  then PET -CT. How soon would you consider a PET
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  relevant? Like post -operatively, you're considering
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  this person might have an infection or it might
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  also just still be the reaction to the operation.
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  How soon is a PET really relevant? I think three
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  months. Three months, yes. And say you had a
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  mildly or questionably positive PET at three
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  months. You know, sometimes there's this question
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  of, and increasingly people are also using antibiotics,
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  and we'll get into that in a minute, they might
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  talk about a repeat PET. So what kind of an interval
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  would you imagine if there was mild infect signs
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  clinically, mild infect signs in the lab, and
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  the PET also gives us sort of a questionable,
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  not a very clear answer, yes or no, and say,
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  you know, you might decide, okay, we're going
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  to try with antibiotics. What kind of an interval
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  might you wait for the next PET? I think this
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  is complicated because it depends on the patient
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  himself and his evolution. The thing is with
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  these things, I don't think anybody knows. Yes.
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  And we're all looking for people with experience
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  to give us sort of what is a reasonable thing
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  to do because there is no clear evidence what
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  should be done. Exactly. So in this situation,
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  I'm curious to know what kind of experience you
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  would have where you say, oh, I once did a PET
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  a month later and it exploded or, you know, I
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  waited a whole year and there was nothing yes
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  i think waiting a whole year it's too long of
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  course yeah but you should repeat it perhaps
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  one one month later and just see if the patient
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  is clinicable stable clinically stable right
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  yeah sure okay good that's helpful um so we're
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  going to move on to medical therapy and we already
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  talked a bit about antibiotics how aggressive
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  should we be do you advocate lifelong suppressive
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  therapy in some patients yes To begin, one important
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  notion is that microbiological proof of infection
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  should be done once infection is suspected before
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  antimicrobial therapy is started. You need to
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  have this proof of infection in order to better
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  target your bacteriology. Antimicrobial therapy
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  is then discussed depending on the surgical strategy.
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  If you could perform a complete removal, a minimum
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  of six weeks. antimicrobial therapy is perhaps
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  enough. But if conservative strategy was decided,
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  lifelong antimicrobial therapy should be discussed.
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  And then we're talking about a difference between
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  a suppressive and a treatment therapy, right?
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  Yes. So two questions. First of all, when you
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  talk about having positive blood cultures, sometimes
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  you don't. You're convinced. You see on the CT
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  there's definitely something happening there.
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  The PET goes positive and you're maybe half a
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  year out of the surgery and the patient has indolent
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  infect signs. And maybe once they also have a
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  little bit of sepsis, but their blood cultures
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  continue to be negative. What would you do in
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  that situation? I would not provide any antimicrobial
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  therapy in this patient before we've got deep.
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  peri -tissue or graft samples to analyze performing
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  sonication in order to have proof of infection.
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  If the patient is clinically stable and has no
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  septic shock for sure. So would you even consider
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  doing a CT controlled puncture of the sac to
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  be able to get this information or would you
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  consider that too risky? It can be done but if
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  you're really convinced there is an infection,
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  you can go to surgery. Okay. How much input from
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  infectious disease colleagues do you rely on?
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  And is there a shared protocol that you've developed
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  at your institution? Or is this really something
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  that the vascular surgeons own? Of course not.
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  Thank you for raising this point. Multidisciplinary
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  team management is mandatory. And yes, we developed
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  a shared protocol in our institution, as well
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  as weekly meetings with the infectious disease
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  colleagues, so we can discuss. A weekly meeting
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  to discuss the cases that need discussing, that's
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  interesting. Exactly. Okay, so the other side
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  of antibiotics, now let's talk about surgery.
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  Complete explant is still considered gold standard
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  by many, but it's high risk. What's your decision
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  -making process in weighing explant versus in
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  -situ reconstruction versus conservative management?
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  Yes, graft removal with in -situ reconstruction
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  is still considered as the gold standard for
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  fit patients because the goal of the treatment
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  is to have infection eradication. But of course,
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  this is not possible for all patients because
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  if the patient is too frail or the intervention
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  is too risky. So in such patients, conservative
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  management with suppressive lifelong antimicrobial
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  therapy can be discussed. But I think it can
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  be seen as a palliative strategy. And in terms
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  of like assessing a patient for frailty is it
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  your experience with the patient knowing them
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  over many years that's going to make that decision
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  or are you doing certain frailty scores or tests
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  or is that really sort of on the side of how
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  you judge the patient to be able to cope with
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  this operation? So this is a multidisciplinary
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  team. discussion because it's the patient. The
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  patient can be fit or can be frail, but it depends
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  also on the complexity of the reconstruction.
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  If this is just an infernal endograft, this is
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  not as complicated as a much complex reconstruction.
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  So it's a lot of things that make the decision.
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  Okay. Do the anesthesiologists often, you know,
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  put a red flag like, you know, you want to change
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  the endograft and you're convinced this would
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  be the only way to go and they stop you? That's
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  exactly true. This is the discussion we need
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  to discuss with the patient, of course, with
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  his family, with the infectious disease specialist,
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  and of course the anesthesiologist, because they
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  can see things that we as surgeons cannot see.
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  Yeah, it's a complex process. So I'd like to
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  ask about in -situ replacement with cryopreserved
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  allograft or rifampicin -soaked prosthetics.
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  There's some literature on this. How do you view
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  the evidence for durability and infection control?
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  Yes, there are several concerns. With cryopreserved
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  allograft, the most feared complication is allograft
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  degeneration and rupture. We saw a lot, so perhaps
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  it's not the best substitute in long term for
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  durability. And according to the infectious disease
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  specialist, rifampicin -bounded grafts are not
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  recommended due to the relatively narrow antimicrobial
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  spectrum and the theoretical risk of developing
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  resistance. So, two questions there. Does that
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  mean that you've taken the allografts out of
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  your repertoire of what you might be using? And
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  secondly, what are you using instead? So, do
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  actual recommendations make it better for deep
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  vein? or other substitutes antimicrobial prosthesis
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  or pericardium tubalized or such conduits but
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  allografts are questionable okay so if you were
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  looking for a deep vein which deep vein are you
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  choosing femoral good thank you for that Let's
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  talk about patient risk factors or patient factors
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  and risk stratification about personalized medicine,
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  the way of modern medicine. Are there patient
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  characteristics, comorbidities, infection, virulence,
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  anatomy that push you strongly towards one strategy
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  or another? Sure. If the patient presents with
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  a fistula, surgical treatment is mandatory. Medical
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  treatment alone will not have success. However,
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  if the patient is frail or if anatomy is too
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  complex, if reconstruction is high risk, long
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  -term suppressive therapy can be discussed. But
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  you need to choose between definitive treatment
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  or palliative strategy. I think it's an individualized
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  strategy with multidisciplinary team discussion
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  for each patient. It's too difficult to draw
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  algorithms in these settings. Do you ever use
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  risk scores or predictive models in your practice?
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  Or is it, as you just said, still very much just
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  an individualized judgment? Yes, exactly. Risk
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  or predictive models, for sure, would be of interest.
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  But I don't use such model in current practice.
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  It is much an individualized judgment after,
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  of course, the multidisciplinary team discussion.
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  Thank you. Now, when we're looking at outcomes,
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  what outcomes are you seeing in your own practice
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  with different strategies? Mortality, reinfection
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  rates? long -term graft patency? So this is a
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  difficult question. I think the best outcomes
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  can be seen when optimal management was performed.
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  So this means multidisciplinary team management,
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  obtention of microbiological proof of infection
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  before you start the antimicrobial therapy, and
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  surgical management with complete graft removal
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  and in -situ reconstruction. Are you very afraid
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  of reinfection when you're doing total surgical
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  replacement? If you ensure a good debridement
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  and you coverage of the new reconstruction with
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  flaps or something like that and with adapted
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  and targeted antimicrobial therapy, this is provision
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  for good outcomes. For patients who survive but
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  are managed with suppressive therapy or partial
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  surgical solutions, what does follow -up look
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  like in your clinic? So follow -up is very close.
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  And this includes clinical examination, laboratory
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  tests, CTA imaging, at least every two months.
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  Two -month follow -ups. That's a nice little
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  insight into your clinical practice. Thank you
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  for that detail. When we're looking about the
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  future, where do you think the biggest controversies
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  lie right now? Is it in diagnosis, surgical management,
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  antibiotic strategy, or all of the above? Where
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  should our focus be? I think the biggest controversies
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  lie on surgical management because we have such
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  different options. Complete removal. partial
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  graft removal graft preservation but also different
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  strategies such as in -situ reconstruction extra
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  anatomic reconstruction and even different conduits
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  so and the available literature we cannot draw
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  valid conclusion because of course there are
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  no air cities the series are very heterogeneous
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  so saying one strategy is better than another
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  is impossible at the moment yeah luckily it's
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  a rare disease but that gives us not an enough
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  data. Of course. So looking forward are there
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  any innovations whether in biomaterials, imaging
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  or perioperative care that you think could really
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  shift the landscape in the next five to ten years?
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  Yes I truly believe that all fields can evolve
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  either antimicrobial therapy, biomaterials, imaging,
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  surgical strategies and even perioperative care.
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  This must shift the landscape in coming years,
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  I'm sure. So you're saying everything at the
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  same time? Yes. Thank you, Dr. Leger. It has
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  been an incredibly insightful discussion. Aortic
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  stent infection may be uncommon, but for those
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  of us who face it, the stakes couldn't be higher.
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  Before we wrap up, what's the one takeaway you'd
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  like vascular surgeons listening to remember
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  when it comes to managing these patients? I think
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  multidisciplinary team management is mandatory
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  and this will help improve outcomes of these
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  patients. Thank you so much for joining us today
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  and thanks to all of you for listening to the
• 15:19
  ESVS podcast. If you enjoyed this episode, please
• 15:21
  share it with your colleagues and subscribe for
• 15:23
  more conversations from the cutting edge of vascular
• 15:25
  surgery. Thank you all for listening and goodbye.
• 15:28
  Thank you, Laurence. Goodbye.