Prosthetic Vascular Graft Infection
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1 Prosthetic Vascular Graft Infection Charito Love, MD Division of Nuclear Medicine & Molecular Imaging North Shore Long Island Jewish Health System Manhasset & New Hyde Park, New York
2 Prosthetic Vascular Graft Surgery Medical device market in USA: $86 billion in 2006, 10% for 2007 (Laredo et al. Encyc Biomaterials Biomed Eng, 2004) 2.3 million prosthetic graft surgeries/year Access for hemodialysis Aortic aneurysm Vascular occlusive disease
3 Prosthetic Vascular Graft Surgery Types of graft materials Autogenous vessels Allograft vessels Heterografts Tissue engineered Synthetic: polyethylene terephthalate (Dacron) polytetrafluoroethylene (PTFE) polyurethane (PU)
4 Failure in Synthetic Vascular Grafts Acute thrombosis: lack of functional endothelium Anastomotic site complications: a) Re-stenosis: foreign material induced chronic inflammatory response b) Aneurysm: compliance mismatch c) Bleeding Infection: foreign material
5 Hemodialysis (HD) Grafts 300,000 pts require vascular access for HD 60% use synthetic grafts (180,000) due to lack of autogenous vessels for AV fistula formation Bacteremia in 48% -73% patients 2 0 to repeated puncture 9% - 35% of synthetic grafts become infected Major source of morbidity: temporary catheter, prolonged hospitalizations Substantial mortality: 12% - 36% deaths
6 HD Grafts Graft infection (n=90)* Within 1 month of surgery: 15% >1 month- 12 months: 44% > 1 year: 41% Must be removed when bacteremia persist *(Minga et al: Am J Kidney Dis 2001)
7 Infection in HD Grafts Clinical presentation Local signs: redness, warmth, swelling, tenderness, drainage No local signs FUO, persistent bacteremia, WBCs Silent graft infection in clotted nonfunctioning grafts* 62% nonfunctioning grafts in febrile patients *(Ayus et al. J Am Soc Nephrol 1998)
8 Diagnostic Imaging Scant literature available Ultrasound: used for imaging thrombosis/ stenosis Labeled leukocyte imaging (WBC) for HD graft infection
9 WBC Imaging (n=) Sensitivity Specificity Accuracy Palestro et al* (JNM 1990) Ayus & Sheik-Hamad (J Am Soc Nephrol 1998) % (15/15) 93% (14/15) 97% (29/30) % (33/33) 75% % (6/8) 95% (39/41) *(Antibiotics treatment no effect on sensitivity)
10 WBC Imaging False (+) results Perigraft bleeding/ hematoma Graft thrombosis < 1 week old post-implantation
11 WBC Imaging For patients with suspected HD graft infection Obtain whole blood from patients day after dialysis Inject labeled leukocyte at another vascular site Image before dialysis
12 111 In-WBC Imaging Forearm graft Lt groin graft
13 Bypass Vascular Graft Surgery For aortic aneurysm and peripheral vascular occlusive disease 7,172 AAA elective repairs with graft: conventional and endovascular surgery (National Inpatient Sample Data, 2001) 14,788 infrainguinal bypass graft surgery (VA NSQIP Registry )
14 Prosthetic Vascular Graft Infection Risk of infection: low Conventional Surgery First Implantation: 1-6% Aortic grafts: % Aorto-femoral grafts: % Infrainguinal grafts: 6% Revision/resection: 22% Endovascular aneurysm repair (EVAR): <0.4%
15 Prosthetic Vascular Graft Infection Morbidity Aortic: 21%- 30% (Loss organ function) Peripheral: 79% (Distal limb occlusion, amputation) Mortality Aortic: 25% -75% Bacteremia/Sepsis Fistula formation: hemorrhage Peripheral grafts: 17% - 22% Bacteremia/Sepsis
16 Prosthetic Vascular Graft Infection Early: 3 months post-surgery Intraoperative/perioperative contamination Poor wound healing (inguinal graft sites) Systemic signs/symptoms present: fever, WBCs, graft dysfunction or anastomotic bleeding Late: > 3 months Graft access, remote infectious site Can be subtle: vague discomfort, limb ischemia Overt: hemorrhage from aorto-enteric fistula
17 Diagnostic Imaging of Prosthetic Vascular Graft Infection Morphologic imaging Sonogram: peripheral grafts MRI: all grafts CT: all grafts Functional imaging (all grafts) Gallium WBC 18 F-FDG
18 Morphologic Imaging Direct visualization of abnormalities Aspiration Fast Challenge Differentiating postoperative changes from infection in grafts 3 months old
19 Postoperative Changes Hematoma Present in all pts Resolves in 7-65 days in 82% pts Resolution around aortic graft faster than femoral grafts Perigraft fluid Resolves over 3 months Perigraft gas Resolves in 1 week Fibrosis/graft incorporation Begins in 2-3 months
20 Ultrasonography Can be performed at bedside Adequate for inguinal/infrainguinal grafts Can guide aspiration Infected graft Perigraft fluid Anechoic-hypoechoic area
21 MRI Can distinguish perigraft fluid & inflammatory changes from subacute to chronic hematoma Cannot distinguish between infected & sterile fluid Criteria for PVGI Perigraft fluid beyond 3 months of surgery Sensitivity 88%, specificity 100%* n= 18 pts, 16 infected, 2 uninfected 2 FN: no perigraft fluid, loss of graft incorporation *Olofsson J Vasc Surg 1988
22 CT Imaging procedure of choice for PVGI High spatial resolution Short imaging time Guide aspiration
23 Criteria for PVGI CT Perigraft fluid- suspicious beyond 3 rd month of surgery Perigraft air- after 7 weeks post-surgery Attenuation of surrounding tissue Pseudoaneurysm Focal bowel thickening Aortic Grafts Sensitivity 94%, specificity 85% Peripheral grafts Sensitivity 100%, specificity 79%
24 10 y/o Infected Aortobifemoral Graft Native Aorta Aortobifemoral Graft Native Femoral Vessels
25 10 y/o Infected Aortobifemoral Graft
26 CT Normal graft (2 wks post-op)
27 CT Normal graft (2 wks post-op) Normal graft (6 mos post-op)
28 CT Normal graft (2 wks post-op) Thrombosed grafts Normal graft (6 mos post-op)
29 CT Normal graft (2 wks post-op) Thrombosed grafts Normal graft (6 mos post-op) Infected graft
30 Radionuclide Imaging
31 Gallium-67 Localizes in area of inflammation Transferrin delivery to inflammation Lactoferrin binding at inflammation Siderophore binding at inflammation Direct bacterial uptake (S. Aureus, E.coli) Macrophage uptake (via gallium receptors) Leukocyte delivery to inflammation Limited in diagnosing aortic graft infection due to overlying GI activity
32 Gallium Imaging Sensitivity Specificity Accuracy Aortic (n=16) 0% (0/2) 93% (13/14) 81% (13/16) Groin (n=24) 100% (5/5) 95% (18/19) 96% (23/24) ALL (n=40) 71% (5/7) 94% (31/33) 90% (36/40) Johnson et al, AJR 1990
33 Gallium vs. CT Modality Graft Site Sensitivity Specificity Accuracy Aortic (n=16) 100% (2/2) 57% (8/14) 63% (10/16) CT Groin (n=24) 100% (5/5) 79% (15/19) 83% (20/24) ALL (n=40) 100% (7/7) 70% (23/33) 75% (30/40) Aortic (n=16) 0% (0/2) 93% (13/14) 81% (13/16) Gallium Groin (n=24) 100% (5/5) 95% (18/19) 96% (23/24) ALL (n=40) 71% (5/7) 94% (31/33) 90% (36/40) Johnson et al, AJR 1990: No statistically significant differences in sensitivity/specificity.
34 Infected Lt. Femoral Graft 67 Ga scan (48 hrs)
35 Labeled Leukocyte (WBC) Serota et al. Surgery Planar 111 In-WBC: Dacron infrarenal aortic graft Days Week/s Infection (+) (n= 6) Infection (-) (n= 6) (+) (+) (+) (+) (+) (+) (+) (+) (-) (-)
36 Planar 111 In-WBC Imaging Sedwitz et al: J Vasc Surg n= 30 patients had WBC imaging before discharge Normal scan ( n= 14) Aortic graft (n=10) Aortobifemoral graft (n=4) Abnormal scan (n=16) Peripheral grafts (n=16) Inguinal wounds (n=16) Decreasing activity over time
37 Planar 111 In-WBC Imaging Mark (AJR, 1985) Williamson (AJR 1986) Brunner (J Vasc Surg 1986) Chung (JNM 1991) Shahidi (Ann Vasc Surg 2007) Grafts Sensitivity Specificity Accuracy n= 8 Aortic, Ao-fem grafts n= 30 variety of grafts n= 67 variety of grafts n= 23 variety of grafts n= 53 Aortic, Ao-femoral, Ao-iliac grafts 60% (3/5) 100% (3/3) 75% (6/8) 100% (13/13) 88% (15/17) 93% (28/30) 100% 14/14 85% (45/53) 88 % (59/67) 100% (10/10) 85% (11/13) 91% (21/23) 73% (16/22) 87% (27/31) 81% (43/53)
38 Planar 99m Tc-WBC Imaging Fiorani (J Vasc Surg 1993) Krznaric (NM Commun 1994) Prats (JNM 1994) Liberatore (EJVES 1997) Muhammad (JPMA 2000) Grafts Sensitivity Specificity Accuracy 37 Aortic, Aofem grafts 21 variety of grafts 75 variety of grafts 97 Ao-femoral grafts 25 Femoral grafts 100% (19/19) 94% (17/18) 97% (36/37) 53% (8/15) 100% (20/20) 100% (61/61) 100% (2/2) 100% (6/6) 100% (55/55) 92% (33/36) 61% (14/23) 67% (14/21) 100% (75/75) 97% (94/97) 64% (16/25)
39 Planar WBC Imaging False (+) results Infectious process near the graft Wound infection Hematoma Pseudoaneurysm Thrombosed graft Immediate post-op period (<1 week)
40 111 In- WBC Imaging Infected 2 month old Rt. Fem-pop bypass graft Infected 2 year old Aortobifemoral graft
41 10 Week Old Endograft Infection versus Post-op changes
42 Infected Endovascular Graft MRI CT 99m Tc- AGA
43 Planar WBC & Morphologic Imaging Mark (AJR, 1985) Modality Sensitivity Specificity Accuracy 111 In-WBC 60% (3/5) 100% (3/3) 75% (6/8) CT 100% (5/5) 100% (3/3) 100% (8/8) Williamson (AJR 1986) 111 In-WBC CT 100% (13/13) 75% (6/8) 88% (15/17) 100% (3/3) 93% (28/30) 82% (9/11) Shahidi (Ann Vasc Surg 2007) 111 In-WBC MRI 73% (16/22) 68% (17/25) 87% (27/31) 97% (32/33) 81% (43/53) 84% (49/58)
44 Infected 2 mo-old Rt. Femoral Graft
45 Infected Aortobifemoral Graft 111 In WBC
46 Infected Aortobifemoral Graft
47 WBC-SPECT/CT Bar-Shalom et al, JNM suspected sites 111 In-WBC (Planar & SPECT) vs. 111 In-WBC SPECT/CT Grafts (n=) Modality Sensitivity Specificity Accuracy 24 (ALL) 111 In-WBC 100% (11/11) 8% (1/13) 50% (12/24) SPECT/CT 100% (11/11) 92% (12/13) 96% (23/24) 4 (Ao-bifem) 111 In-WBC 100% (2/2) 0% (0/2) 50% (2/4) SPECT/CT 100% (2/2) 100% (2/2) 100% (4/4) 20 (Peripheral) 111 In-WBC 100% (9/9) 9% (1/11) 50% (10/20) SPECT/CT 100% (9/9) 91% (10/11) 95% 19/20)
48 111 In-WBC SPECT/CT* 54 y/o male, 2 y/o left femoropopliteal bypass and 2 month-old right femoropopliteal bypass grafts, presented with infected surgical wound in the right groin. Surgical wound improved with systemic Abx and local Tx. No evidence of graft infection at 10-month follow-up *Bar-Shalom, JNM 2006
49 Effect of Antibiotics on WBC Imaging Chung et al. JNM 1991: No effect on sensitivity of WBC imaging Sensitivity: 100% (10/10), Specificity 85% (11/13), Accuracy 91% (21/23)
50 Effect of Antibiotics on WBC Imaging Nov 2001 Dec 2001 Jan 2002
51 18 F-FDG-PET Stumpe (Eur JNM 2000) Fukuchi (J Vasc Surg 2005) Lauwers (Agiology 2008) Grafts Sensitivity Specificity Accuracy 6 Aortic 1 Inguinal 33 Aortic 2 Aortobifem 7 Peripheral 100% (2/2) 100% (5/5) 100% (7/7) 91% (10/11) 100% (3/3) 64% (14/22) 33% (2/6) 73% (24/33) 56% (5/9)
52 18 F-FDG PET False (+) results Grafts 2 months old Healing grafts
53 18 F-FDG-PET vs. CT Fukuchi (J Vasc Surg 2005) Lauwers (Angiology 2008) Grafts Sensitivity Specificity Accuracy CT 64% (7/11) 86% (19/22) 79% (26/33) FDG-PET 91% (10/11) 64% (14/22) 73% (24/33) CT 33% (1/3) 50% (1/2) 40% (2/5) FDG-PET 100% (3/3) 33% (2/6) 56% (5/9)
54 18 F-FDG-PET/CT Keidar et al., JNM pts with suspected graft infection 69 total grafts imaged: 40 suspected, 29 not suspected of infection. Aortobifem (n= 20) Femoropopliteal (n= 31) Other (n=18) Age, type, site of graft provided
55 18 F-FDG-PET/CT Grafts Sensitivity Specificity Accuracy Keidar (JNM 2007) n= 39 n= 18 ( 3 months old) 93% (14/15) 83% (5/6) 92% (22/24) 83% (10/12) 92% (36/39) 83% (15/18) False (+) results due to infected hematoma Accurately identified nearby soft tissue infection No evidence of infection in normal 18 F-FDG-PET/CT High negative predictive value
56 Surgical Wound Infection 68 y/o pt, left femoropopliteal bypass graft placed 18 months previously, presented with fever & infected wound in the left thigh medially. (Keidar et al. JNM 2007)
57 Infected Prosthetic Vascular Graft 65 y/o patient, multiple prosthetic bypass graft surgeries, presented with fever & right thigh pain and swelling. Courtesy: Zohar Keidar MD. PhD. Deputy Director Department of Nuclear Medicine Rambam Health Care Campus Haifa, Israel
58 Asymptomatic Aortic Graft Sept 2006 SUV Max: 8.4 July 2007 SUV Max: 15.2
59 Prosthetic Vascular Graft Infection CT is the imaging procedure of choice Useful for patients with grafts > 3 months old WBC imaging complementary to CT Especially for grafts < 3 months old 18 F-FDG PET & PET/CT Initial results encouraging Further investigations needed
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