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Editor's Choice - Outcomes of Aortic Graft and Endograft Infection Using Management of Aortic Graft Infection
Oliver Lyons1, Ash Sivaharan2, George Gradinariu3
1Department of Surgery, University of Otago, Christchurch, New Zealand; Vascular Endovascular and Transplant Surgery, Christchurch Public Hospital, Christchurch, New Zealand.
Insights
Vascular graft and endograft infection (VGEI) requires diligent follow-up. A normal C-reactive protein (CRP) level at initial presentation can exclude VGEI, but suspected cases need at least two years of monitoring.
Area of Science:
- Vascular Surgery
- Infectious Diseases
- Diagnostic Imaging
Background:
- Aortic vascular graft and endograft infection (VGEI) diagnosis is critical for patient outcomes.
- The Management of Aortic Graft Infection Collaboration (MAGIC) criteria aid in VGEI assessment.
- Distinguishing suspected from definitively diagnosed VGEI is essential for appropriate management.
Purpose of the Study:
- To investigate the progression of suspected to definitively diagnosed VGEI.
- To establish evidence-based follow-up recommendations for VGEI.
- To determine the utility of inflammatory markers in excluding VGEI and minimizing unnecessary interventions.
Main Methods:
- Prospective follow-up of 188 patients meeting MAGIC criteria for suspected or diagnosed VGEI.
- Systematic recording of clinical, radiological, and laboratory features during follow-up.
- Analysis of diagnostic criteria progression and patient outcomes.
Main Results:
- 83% of patients with suspected VGEI were definitively diagnosed during follow-up.
- C-reactive protein (CRP) ≥ 2 mg/L showed 100% sensitivity for diagnosed VGEI.
- A normal CRP level at presentation excluded later VGEI diagnosis, unlike total leucocyte count.
Conclusions:
- Suspected VGEI warrants a minimum of two years of follow-up due to progression.
- Regular review and comprehensive investigation are crucial for managing suspected VGEI.
- Normal CRP levels at initial presentation are valuable for excluding VGEI.
Objective:
Confirmation of aortic vascular graft and endograft infection (VGEI) is highly consequential in terms of intervention and prognosis. Using the Management of Aortic Graft Infection Collaboration (MAGIC) definition, this study aimed to investigate the progression of suspected to definitively diagnosed VGEI to derive evidence based follow up recommendations and to determine the utility of routine inflammatory markers to definitively exclude VGEI and thereby minimise unnecessary high risk intervention.
Methods:
One hundred eighty-eight patients fulfilling MAGIC criteria for suspected or diagnosed VGEI were followed prospectively. Multidisciplinary clinical teams recorded baseline and subsequent development of new diagnostic features (clinical, radiological, and laboratory) and outcomes.
Results:
The duration of follow up of survivors was a median 2.9 (range 0.6 - 8.3) years. At presentation, 78 of 188 (41%) patients reached the suspected threshold, and 110 (59%) reached the definitive diagnostic threshold. During follow up, a further 46 of 78 (59%) suspected cases acquired additional criteria so that, overall, VGEI was definitively diagnosed in 156 of 188 (83%) patients. The sensitivity of C reactive protein (CRP) ≥ 2 mg/L at presentation for diagnosed VGEI was 100%, 97% for CRP ≥ 5 mg/L, and 96% for CRP ≥ 10 mg/L. In contrast, the sensitivity of abnormal total leucocyte count (≥ 11 x109/L) was 51%. Patients with initially suspected or diagnosed VGEI had similar overall survival (p = ns, log rank).
Conclusion:
Using the MAGIC criteria, suspected VGEI should receive a minimum of two years follow up, since over half progress to diagnosed VGEI within one year. Underscoring the importance of regular review and extensive investigation, suspected cases have indistinguishable survival from those meeting the diagnosed threshold at presentation. In this series, a normal CRP level (but not total leucocyte count) at initial presentation excluded the later diagnosis of VGEI.
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