Management of graft infection after EVAR-TEVAR. Can PET-CT predict the outcome of prosthetic graft infections?

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1 Management of graft infection after EVAR-TEVAR. Can PET-CT predict the outcome of Imane El hassani, Martin Moïse, Roland Hustinx Jean-Olivier Defraigne & Natzi Sakalihasan Department of Cardiovascular and Thoracic Surgery University hospital of Liège, Experimental Research Center of the Cardiovascular Surgery Department, GIGA-Cardiovascular Science Unit, University of Liège, Liège, BELGIUM

2 Disclosure of Interest Speaker name: Sakalihasan Natzi I do not have any potential conflict of interest

3 BACKGROUND Despite adequate medical management, aortic graft infection, with incidence of 1-6%, remains a complication with high morbidity and mortality of aortic surgery. Aim of the study To explore aortic 18 F-FDG uptake by PET/CT imaging in patients with suspected aortic graft infection after EVAR/TEVAR, to predict and to investigate potential associations between outcome and PT/CT imaging.

4 Value of FDG-PET, CT and fused PET/CT in low grad vascular prosthetic graft infection Sensitivity Specificity FDG-PET 91% 64% CT 55-64% 86% FDG-PET/CT 93% 91%

5 Material & Methods 311 consecutive patients (264 male) Mean age:70 years (24 years 94 years). EVAR for AAA (234). TEVAR for TAA (37). TEVAR for THORACIC AORTIC DISSECTION (24). TEVAR for Isthmic Rupture (10). EVAR for Thoraco Abdominal Aneurysm (6)

6 311 consecutive patients 10 (3,2%) patients with suspected graft infection Hyperthermia, increased WBC, CRP, alteration of general status and positive blood culture. ( CT ) PET-CT performed in 10 patients 6 (1,9%) patients with (+) PET-CT 4 EVAR 2 TEVAR

7 Patient characteristics with (+) PET-CT Characteristis N=6 (%) Gender (male/female) 5 83% Age 73 Smoking 5 83% Hypertension 2 33% Diabetes mellitus 1 17% Symptoms Fever 4 67% Pain 2 33% Increased WBC 3 50% Increased CRP 5 83% (+) Blood Culture 3 50%

8 Summary of a cohort of 10 Patients Patient ID/sex Age Type of treatment Delay between surgery and clinical signe of infection (weeks) PET status Lenght of antibiotics (weeks) Conversion to Open Surgery Outcome 1 /M 59 EVAR* (aortitis!!!) + 80 YES (removal) Kidney transplantation, full recovery 2/M 73 EVAR YES (removal) Full recovery 3/M 73 EVAR NO (poor risk) DIED 4/M 77 TEVAR/EVA R NO (poor risk) DIED 5/M 72 TEVAR NO ALIVE 6/F 79 TEVAR** Oesophageal prosthesis 7/M 83 EVAR 3-2 NO Alive 8/M 79 TEVAR*** 52-6 NO Alive 9/M 74 EVAR*** 1-1 NO Alive 10/M 68 FEVAR No Alive * Patient underwent emergency surgery for aorto-duedenal fistula. ** Patient presenting aorto-oesophageal fistula *** Two patients with non vascular infection. DIED

9 Outcome of patients with (+) PET-CT Removal (n=2) Conservative treatment (n=4) mortality 0 (0%) 3 (75%) Systemic complications 1 (50%) 0

10 Male Patient No 1 (emergency surgery for aorto-duedenal fistula)

11 3 weeks after transfer to Liege Three blood cultures: negative!!!!!

12 CRP : 22mg/l CRP:20 mg/l CRP: 35mg/l CRP :25,9mg/l CRP : 118,6 mg/l WBC : 6100 mm 3 WBC7970 WBC:9120 WB :9260 WBC:10470

13 Melena,anemia (Hgb:7g/dl, CRP:46,4mg/l, WBC:12.490mm 3) Endoscopy:perforation caused by underlying aortic prosthesis. Endoprosthesis and D3, both surgically removed and an axillo-femoral bypass was performed.

14 Male patient No 2,( EVAR in September 2009), November 2009, fever, alteration of clinical status

15 Female patient No 6 (TEVAR complicated by aorto-oesophageal fistula)

16 12/ /2016 Male Patient No 5 (TEVAR 09/2015)

17 Summary The incidence of graft infection in our institution is 1,9 % after EVAR and/or TEVAR The mortality rate in patients with increased 18F-FDG uptake despite IV antibiotics is very high (50%).

18 conclusion In the lights of case series, we consider 18 F-FDG PET/CT may be a precious and reliable predictive tool of treatment of graft infection success. We suspect its positivity as a strong clue of inevitable subsequent prosthetic excision intervention. 18 F-FDG PET/CT could likewise prove its utility in determining antibiotic treatment length by monitoring response to medical therapy, whose significance is not to be forgotten.