Guideline sources The following summarized guidelines for the evaluation and management of vascular graft infection (VGI) are prepared by our editorial team based on guidelines from the European Society for Vascular Surgery (ESVS 2020) and the American Heart Association (AHA 2016). 1 2 Guidelines 1. Diagnostic investigations Initial evaluation: obtain comprehensive evaluation of clinical status, signs of infection and patient comorbidities according to the MAGIC criteria in patients with suspected VGI. B Microbiologic testing: attempt to obtain microbiological proof of infection in patients with suspected VGI. B Show 3 more Diagnostic imaging: As per ESVS 2020 guidelines, obtain CT angiography as the first-line diagnostic modality in patients with suspected VGI. B Consider obtaining MRA if CT angiography is contraindicated. B Show 3 more As per AHA 2016 guidelines, consider obtaining CT angiography as the initial imaging in patients with suspected intra-abdominal VGI. C Show 6 more https://web.pathway.md/diseases/recur4G0sFhR2tc92 1/4 6/29/23, 3:24 AM Vascular graft infection Pathway 2. Medical management General principles: As per ESVS 2020 guidelines, transfer patients to a specialized high volume center with multidisciplinary experience in this pathology for the diagnosis and treatment of VGI. B As per AHA 2016 guidelines, ensure a multidisciplinary team approach including specialists in vascular and cardiovascular surgery, vascular medicine, cardiology, infectious diseases, and radiology for the management of patients with VGI. B Antibiotic therapy: initiate antimicrobial therapy in all patient with an infected graft/endograft. B Management of supra-aortic trunk VGI: consider obtaining further investigations to exclude a VGI when patch corrugation is found on follow-up ultrasound after carotid endarterectomy. C Show 4 more Management of thoracic aorta VGI: As per ESVS 2020 guidelines, obtain further diagnostic investigations for infection in patients with persistent fever or inflammatory symptoms after implantation of a thoracic graft/endograft. B Show 8 more As per AHA 2016 guidelines, consider performing in situ repair of cryopreserved arterial allografts. C Show 2 more Management of aorto-esophageal fistula: As per ESVS 2020 guidelines, perform explantation of the infected material, repair of the esophagus and coverage with viable tissue as definitive treatment in patients with aorto- esophageal fistula complicating thoracic/thoraco-abdominal VGI. B Show 3 more As per AHA 2016 guidelines: Consider performing thoracic endovascular therapy to control bleeding and stabilize hemodynamics and as a bridge therapy to device explantation and open surgical repair in patients with aorto-esophageal fistula. C Consider initiating lifelong suppressive antibiotic therapy along with endovascular therapy or in situ repair after the initial course of 6-8 weeks of antimicrobial therapy. C Management of aorto-bronchial/pulmonary fistula: As per ESVS 2020 guidelines, consider performing closure of the airway defect and explantation of the infected material with in situ reconstruction as definitive treatment in patients with aorto-bronchial or aorto-pulmonary fistula complicating thoracic/thoraco- abdominal VGI. C Show 2 more As per AHA 2016 guidelines: Consider performing transthoracic endovascular repair for the management of aorto- bronchial fistula in preference to open surgical repair because of the high operative risk https://web.pathway.md/diseases/recur4G0sFhR2tc92 2/4 6/29/23, 3:24 AM Vascular graft infection Pathway with open surgical repair as a temporizing measure or in patients unable to tolerate open repair. C Consider initiating lifelong suppressive therapy after the initial courseo of 6-8 weeks of antimicrobial therapy in patients with a retained endovascular device. C Management of abdominal aorta VGI: As per ESVS 2020 guidelines, consider performing percutaneous drainage of peri-graft fluid with or without irrigation for microbiological identification and to reduce the bacteriological burden, but not as ultimate treatment in patients with abdominal aortic graft infection. C Show 11 more As per AHA 2016 guidelines, consider performing graft excision and in situ reconstruction with cryopreserved, arterial allograft, or venous autograft or rifampin-bonded synthetic graft in patients with intra-abdominal VGI without aorto-enteric fistula. C Show 4 more Management of peripheral artery VGI: As per ESVS 2020 guidelines, perform in situ reconstruction with autologous vein in patients with peripheral VGI if removal of the infected graft is likely to lead to limb ischemia. B Show 4 more As per AHA 2016 guidelines, consider initiating a trial of antimicrobial therapy with or without surgical debridement for 2 or 4 weeks in patients with Samson class I or II VGI. C Show 8 more Management of endovascular device infection: consider performing device explantation and in situ reconstruction in patients with abdominal or thoracic endovascular device infection. C Show 2 more 3. Preventative measures Antibiotic prophylaxis: As per ESVS 2020 guidelines, administer an IV first- or second-generation cephalosporin, or vancomycin in the event of penicillin allergy, as antimicrobial prophylaxis to cover the first 24 hours in all patients with an implanted vascular graft/endograft. A Show 2 more As per AHA 2016 guidelines: Consider administering perioperative -lactam antibiotics for the prevention of wound infection in patients undergoing clean vascular graft surgery. C Consider administering perioperative -lactam antibiotics in patients undergoing endovascular device placement. C Clinical findings Symptoms Past medical history Abdominal pain Gastrointestinal bleeding Chills Sepsis https://web.pathway.md/diseases/recur4G0sFhR2tc92 3/4 6/29/23, 3:24 AM Vascular graft infection Pathway Fever Abdominal exam Leg pain Malaise Abdominal distension Past surgical history Lab findings Endovascular stent grafting ESR serum CRP Integument exam Microbiological findings Drainage from the incision site Draining sinus tract blood bacterial culture Palpable mass Purulent exudate Skin abscess Skin erythema Skin induration Hematological findings WBC count Imaging findings Peri-graft fluid collection Peri-graft gas collection Peri-graft soft tissue alterations Pseudoaneurysm Vascular graft occlusion References 1. Walter R Wilson, Thomas C Bower, Mark A Creager et al. Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement From the American Heart Association. Circulation. 2016 Nov 15;134 20):e412-e460. Open 2. Nabil Chakf , Holger Diener, Anne Lejay et al. Editor's Choice European Society for Vascular Surgery ESVS 2020 Clinical Practice Guidelines on the Management of Vascular Graft and Endograft Infections. Eur J Vasc Endovasc Surg. 2020 Mar;59 3 339 384. Open 3. O T A Lyons, M Baguneid, T D Barwick et al. Diagnosis of Aortic Graft Infection: A Case Definition by the Management of Aortic Graft Infection Collaboration MAGIC . Eur J Vasc Endovasc Surg. 2016 Dec;52 6 758 763. Open https://web.pathway.md/diseases/recur4G0sFhR2tc92 4/4