Three-Dimensional Geometric Analysis of Viabahn VBX Bridging Stent Grafts in Fenestrated Endovascular Aortic Repair: A Multicenter, Retrospective Cohort Study.

PURPOSE: The primary aim of this study was to assess the 3-dimensional flare geometry of the Gore Viabahn VBX balloon-expandable covered stent (BECS) after fenestrated endovascular aortic repair (FEVAR) and to determine and visualize BECS-associated complications. METHODS: This multicenter retrospective study included patients who underwent FEVAR between 2018 and 2022 in 3 vascular centers participating in the VBX Expand Registry. Patients with at least one visceral artery treated with the VBX and with availability of 2 post-FEVAR computed tomography angiography (CTA) scans (follow-up [FU] 1: 0-6 months; FU2: 9-24 months) were included. The flare geometry of the VBX, including flare-to-fenestration distance, flare-to-fenestration diameter ratio, flare angle, and apposition with the target artery were assessed using a vascular workstation and dedicated CTA applied software. RESULTS: In total, 90 VBX BECS were analyzed in 43 FEVAR patients. The median CTA FU for FU1 and FU2 was 35 days (interquartile range [IQR], 29-51 days) and 14 months (IQR, 13-15 months), respectively. The mean flare-to-fenestration distance was 5.6±2.0 mm on FU1 and remained unchanged at 5.7±2.0 mm on FU2 (p=.417). The flare-to-fenestration diameter ratio was 1.19±0.17 on FU1 and remained unchanged at 1.21±0.19 (p=.206). The mean apposition length was 18.6±5.3 mm on FU1 and remained 18.6±5.3 mm (p=.550). The flare angle was 31°±15° on FU1 and changed to 33°±16° (p=.009). On FU1, the BECS-associated complication rate was 1%, and the BECS-associated reintervention rate was 0%. On FU2, the BECS-associated complication rate was 3%, and the BECS-associated reintervention rate was 1%. CONCLUSIONS: The flare geometry of the VBX bridging stent did not change significantly during 14 months follow-up in this study. Three-dimensional geometric analysis of the flare may contribute to identify the origin of endoleaks and occlusions, but this should be confirmed in a larger study including enough patients and BECS to compare complicated and uncomplicated cases. CLINICAL IMPACT: The three-dimensional flare geometry of the Gore Viabahn VBX BECS was assessed on the first and second postoperative CTA scans, and geometrical changes during this period were identified. For BECS that were diagnosed with a type 3c endoleak or occlusion, the BECS geometry was analyzed to detect geometrical components that were related to the complication. Geometric analysis of the flare may help to better detect and identify the cause of such complications.

Similar long-term outcomes for venous, bovine pericardial, and polyester patches for primary carotid endarterectomy.

BACKGROUND: Currently, the type of patch used for carotid endarterectomy closure depends on the preference of the operating surgeon. Various materials are available, including autologous venous patches, bovine pericardial patches (BPP), and synthetic patches. The purpose of this study was to compare the long-term outcomes. METHODS: All patients who underwent primary carotid endarterectomy with patch angioplasty using a venous, bovine, or polyester patch between 2010 and 2020 at two high-volume medical centers were included in this retrospective analysis on largely prospectively collected data. Study endpoints included long-term ipsilateral transient ischemic attack or cerebrovascular accident, restenosis, reintervention, and all-cause mortality. Cox proportional hazard models were fitted to assess the effect of patch type to each outcome. RESULTS: In total, 1481 CEAs were performed with a follow-up of 32 (13-65) months. Venous patch was used in 309 patients (20.9%), BPP in 1000 patients (67.5%), and polyester patch in 172 patients (11.6%). A preoperative symptomatic carotid artery stenosis of >50% was observed in 91.9% (n = 284) of the patients who received a venous patch, 92.1% (n = 921) of the patients who received BPP, and 90.7% (n = 156) of the patients who received a polyester patch (p = 0.799). Only in selected patients with an asymptomatic stenosis of >70% surgery was considered. Multivariable analyses showed no significant differences between the three patch types regarding long-term outcomes after adjusting for confounders. CONCLUSIONS: In patients undergoing primary carotid endarterectomy, the use of venous, bovine pericardial, or polyester patches seems equally safe and durable in terms of comparability in long-term outcomes.

Patch angioplasty during carotid endarterectomy using different materials has similar clinical outcomes.

OBJECTIVE: Patch angioplasty during carotid endarterectomy (CEA) is commonly used to treat carotid artery stenosis. However, the choice of which patch to use remains a matter of debate. Autologous venous material has disadvantages such as wound-related problems at the harvest site and a prolonged intervention time. These limitations can be bypassed when synthetic or biological patches are used. Both materials have been associated with divergent advantages and disadvantages. Therefore, the aim of our study was to compare the long-term follow-up outcomes in patients who underwent CEA and closure with either a bovine pericardial patch (BPP) or polyester patch. METHODS: A retrospective cohort study was conducted including all patients who underwent primary CEA and closure with a BPP or a polyester patch between January 2010 and December 2020 at our tertiary referral center. In 2015, the BPP was introduced as an alternative for polyester. The primary outcome was the occurrence of transient ischemic attack (TIA) or cerebrovascular accident (CVA) during follow-up and secondary outcomes included restenosis, reintervention, all-cause mortality, and patch infection. Cox proportional hazard models were used and hazard ratios with 95% confidence intervals were used to predict these outcomes. RESULTS: We included 417 CEA patients; 254 patients (61%) received a BPP and 163 received (39%) a polyester patch. The mean age was 70.2 ± 8.7 years and 67% were male. The median follow-up time was 15 months (range, 12-27 months) for BPP and 42 months (range, 16-60 months) for polyester (P < .001). Postoperative hematoma (≤30 days) was significantly lower in the BPP cohort (2% BPP vs 6% polyester; P = .047). No other significant differences on short-term outcomes were found. Univariable Cox regression analyses showed no significant differences between the effect estimates of polyester and BPP on TIA or CVA (P = .106), restenosis (P = .211), reintervention (P = .549), or all-cause mortality (P = .158). No significant differences were found after adjusting for confounders in the multivariable analyses: TIA or CVA (P = .939), restenosis (P = .057), reintervention (P = .193) and all-cause mortality (P = .742). Three patients with a polyester patch had patch infection compared with none of the patients in the group who received a BPP. CONCLUSIONS: This large retrospective study showed comparable safety and durability of both BPP and polyester suggesting that both patch types can be safely applied for CEA with patch angioplasty. Patch infection was rare and was absent in the BPP group.

Variability of [18F]FDG-PET/LDCT reporting in vascular graft and endograft infection.

PURPOSE: 18F-fluoro-D-deoxyglucose positron emission tomography with low dose and/or contrast enhanced computed tomography ([18F]FDG-PET/CT) scan reveals high sensitivity for the diagnosis of vascular graft and endograft infection (VGEI), but lower specificity. Reporting [18F]FDG-PET/CT scans of suspected VGEI is challenging, reader dependent, and reporting standards are lacking. The aim of this study was to evaluate variability of [18F]FDG-PET/low dose CT (LDCT) reporting of suspected VGEI using a proposed standard reporting format. METHODS: A retrospective cohort study was conducted including all patients with a suspected VGEI (according to the MAGIC criteria) without need for urgent surgical treatment who underwent an additional [18F]FDG-PET/LDCT scan between 2006 and 2022 at a tertiary referral centre. All [18F]FDG-PET/LDCT reports were scored following pre-selected criteria that were formulated based on literature and experts in the field. The aim was to investigate the completeness of [18F]FDG-PET/LDCT reports for diagnosing VGEI (proven according to the MAGIC criteria) and to evaluate if incompleteness of reports influenced the diagnostic accuracy. RESULTS: Hundred-fifty-two patients were included. Median diagnostic interval from the index vascular surgical procedure until [18F]FDG-PET/LDCT scan was 35.5 (7.3-73.3) months. Grafts were in 65.1% located centrally and 34.9% peripherally. Based on the pre-selected reporting criteria, 45.7% of the reports included all items. The least frequently assessed criterion was FDG-uptake pattern (40.6%). Overall, [18F]FDG-PET/LDCT showed a sensitivity of 91%, a specificity of 72%, and an accuracy of 88% when compared to the gold standard (diagnosed VGEI). Lower sensitivity and specificity in reports including ≤ 8 criteria compared to completely evaluated reports were found (83% and 50% vs. 92% and 77%, respectively). CONCLUSION: Less than half of the [18F]FDG-PET/LDCT reports of suspected VGEI met all pre-selected criteria. Incompleteness of reports led to lower sensitivity and specificity. Implementing a recommendation with specific criteria for VGEI reporting is needed in the VGEI-guideline update. This study provides a first recommendation for a concise and complete [18F]FDG-PET/LDCT report in patients with suspected VGEI.

Performance of the BioIntegral Bovine Pericardial Graft in Vascular Infections: VASCular No-REact Graft Against INfection Study.

BACKGROUND: Vascular graft and endograft infections (VGEI) and native vessel infections (NVI) remain considerable challenges in vascular surgery, leading to high mortality and morbidity rates. Although in situ reconstruction is the preferred treatment, the material of choice is still a source of debate. Autologous veins are considered the first choice; however, xenografts may be an acceptable alternative. The performance of a biomodified bovine pericardial graft is assessed when implemented in an infected vascular area. METHODS: This is a prospective multicenter cohort study. Patients who underwent reconstruction for VGEI or NVI with a biomodified bovine pericardial bifurcated or straight tube graft were included from December 2017 until June 2021. The primary outcome measure was reinfection at mid-term follow-up. Secondary outcome measures included mortality, patency, and amputation rate. RESULTS: Thirty-four patients with vascular infections were included, of which 23 (68%) had an infected Dacron prosthesis after primary open repair and 8 (24%) had an infected endovascular graft. The remaining 3 (9%) had infected native vessels. At secondary repair, 3 (7%) patients had an in situ aortic tube reconstruction, 29 (66%) had an aortic bifurcated reconstruction, and 2 (5%) had an iliac-femoral reconstruction. At 1-year follow-up after the BioIntegral bovine pericardial graft reconstruction, the reinfection rate was 9%. The 1-year infection-related and procedure-related mortality rate was 16%. The occlusion rate was 6% and in total 3 patients underwent a lower limb amputation during the 1-year follow-up period. CONCLUSIONS: In situ reconstruction as treatment of (endo)graft and native vessel infections remains a challenge and reinfection looms as a potential consequence. In cases where time is of essence or when autologous venous repair is not feasible, a swift available solution is needed. The BioIntegral biomodified bovine pericardial graft may be an option as it shows reasonable results in terms of reinfection, in aortic tube and bifurcated grafts.

Use of Omniflow® II Biosynthetic Graft for the Treatment of Vascular Graft and Endograft Infections.

BACKGROUND: Vascular graft/endograft infection is a rare but life-threatening complication of cardiovascular surgery and remains a surgical challenge. Several different graft materials are available for the treatment of vascular graft/endograft infection, each having its own advantages and disadvantages. Biosynthetic vascular grafts have shown low reinfection rates and could be a potential second best after autologous veins in the treatment of vascular graft/endograft infection. Therefore, the aim of our study was to evaluate the efficacy and morbidity of Omniflow® II for the treatment of vascular graft/endograft infection. METHODS: A multicenter retrospective cohort study was performed to evaluate the use of Omniflow® II in the abdominal and peripheral region to treat vascular graft/endograft infection between January 2014 and December 2021. Primary outcome was recurrent vascular graft infection. Secondary outcomes included primary patency, primary assisted patency, secondary patency, all-cause mortality, and major amputation. RESULTS: Fifty-two patients were included with a median follow-up duration of 26.5 (10.8-54.8) months. Nine (17%) grafts were implanted in intracavitary position and 43 (83%) in peripheral position. Most grafts were used as femoral interposition (n = 12, 23%), femoro-femoral crossover (n = 10, 19%), femoro-popliteal (n = 8, 15%), and aorto-bifemoral (n = 8, 15%) graft. Fifteen (29%) grafts were implanted extra-anatomically and 37 (71%) in situ. Eight patients (15%) presented with reinfection during follow-up, most of these patients received an aorto-bifemoral graft (n = 3, 38%). Intracavitary vascular grafting had a 33% (n = 3) reinfection rate and peripheral grafting 12% (n = 5; P = 0.025). The estimated primary patencies at 1, 2, and 3 years were 75%, 72%, and 72% for peripherally located grafts and 58% (at all timepoints) for intracavitary grafts (P = 0.815). Secondary patencies at 1, 2, and 3 years were 77% (at all timepoints) for peripherally located prostheses and 75% (at all timepoints) for intracavitary prostheses (P = 0.731). A significantly higher mortality during follow-up was observed in patients who received an intracavitary graft compared to patients with a peripheral graft (P = 0.003). CONCLUSIONS: This study highlights the efficacy and safety of the Omniflow® II biosynthetic prosthesis for the treatment of vascular graft/endograft infection, in absence of suitable venous material, with acceptable reinfection, patency, and freedom of amputation prevalences, especially in replacing peripheral vascular graft/endograft infection. However, a control group with either venous reconstruction or another alternative graft is needed to make firmer conclusions.

Patient-Tailored Approach for Diagnostics and Treatment of Mycotic Abdominal Aortic Aneurysm.

BACKGROUND: The existing literature on mycotic aortic aneurysm is scarce and focuses on treatment. This study evaluates the clinical characteristics, diagnostics, treatment and outcome of patients with a mycotic abdominal aortic aneurysm treated in a tertiary referral center. METHODS: A retrospective cohort study was conducted including all patients with a proven mycotic abdominal aortic aneurysm admitted between May 2010 and July 2020. Primary outcome was mortality and secondary outcome included complications such as vascular graft/endograft infection. RESULTS: Twenty-four patients with a mycotic abdominal aortic aneurysm were included. Patients had a mean age of 68 ± 9 years and 20 (83%) were male. Thirteen patients (57%) had positive preoperative blood cultures. Streptococcus pneumoniae was most frequently isolated by blood culturing, pus, and vascular, or perivascular tissue cultures (17%). In 19 (83%) patients the mycotic abdominal aortic aneurysm was located infrarenally, in three (13%) patients suprarenally, and in one (4%) patient juxtarenally. Median follow-up was 20 (7-42) months. In 8 patients (33%) vascular graft and or endograft infection was diagnosed after surgical repair. Ten (42%) patients died during the follow-up period. The main causes of death were vascular graft/endograft infection-related (n = 4) and rupture of the mycotic abdominal aortic aneurysm (n = 3). No patient characteristics could be identified as predictive for mortality. CONCLUSIONS: This study shows a large variation in presentation, diagnostic approaches, and surgical and antibiotic treatment of mycotic abdominal aortic aneurysm. The detailed information about the diagnostic approaches to this rare disease and its antibiotic and/or other treatment contributes to existing knowledge of mycotic abdominal aortic aneurysm. Because of the individual variation patients should be discussed in a multidisciplinary team with a vascular surgeon, infectious disease specialist, and clinical microbiologist.

Frozen Elephant Trunk Completion: Endovascular Extension in The Distal Thoracic Aorta.

INTRODUCTION: Complex pathologies involving the aortic arch can be treated using the frozen elephant trunk (FET) technique, which is versatile and continues to be improved with different innovations to further reduce, for example, circulatory arrest time and the need for hypothermia. FET may or may not be a definitive repair, however. Distal extension or completion-especially endovascular-is common but not well described in the literature. This review describes the considerations that are necessary during FET planning and preparation, how pathology specifics and sizing decisions will affect the subsequent need for treatment, and how outcomes might be better reported to improve understanding of the advantages and limitations of the technique. MATERIALS AND METHODS: This literature review was performed to identify reports of second-stage endovascular completion after FET repair, and included any literature that described such interventions after index FET, for any aortic arch pathology. RESULTS: Secondary intervention after FET is an important parameter to establish the success or failure of the index procedure. However, unplanned extensions are often reported with insufficient detail and follow up, and studies rarely differentiate between unplanned or adjunctive procedures. In addition, prediction of the need for extension is complicated by the response of the pathology to the index procedure. CONCLUSION: FET is a versatile, established surgical technique that allows for several applications in different pathologies and innovative adaptations. How, when, and why FET is extended needs to be reported in greater detail, with specific consideration given to the interaction of FET and endovascular devices in sizing, integrity, and possible complications.

Position Paper on Young Vascular Surgeons Training of the Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS): State of the Art and Perspectives.

The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded in 2018, with the aim to promote cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic peripheral artery was selected as the very first topic to be investigated by the federation. In this second paper, different experiences from delegates of participating countries were shared to define common strategies to harmonize, standardize, and optimize education and training in the Vascular Surgery specialty.

A systematic review and meta-analysis of 18F-fluoro-d-deoxyglucose positron emission tomography interpretation methods in vascular graft and endograft infection.

OBJECTIVE: Vascular graft and endograft infection (VGEI) has high morbidity and mortality rates. Diagnosis is complicated because symptoms vary and can be nonspecific. A meta-analysis identified 18F-fluoro-d-deoxyglucose positron emission tomography-computed tomography (18F-FDG PET/CT) as the most valuable tool for diagnosis of VGEI and favorable to computed tomography as the current standard. However, the availability and varied use of several interpretation methods, without consensus on which interpretation method is best, complicate clinical use. The aim of this study was to evaluate the diagnostic performance of different interpretation methods of 18F-FDG PET/CT in diagnosis of VGEI. METHODS: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data sources included PubMed/MEDLINE, Embase, and Cochrane Library. A meta-analysis was conducted on the different interpretation methods for 18F-FDG PET/CT in diagnosis of VGEI, including visual FDG uptake intensity, visual FDG uptake pattern, and quantitative maximum standardized uptake (SUVmax). RESULTS: Of 613 articles, 13 were included (10 prospective and 3 retrospective articles). The FDG uptake pattern method (I2 = 26.2%) showed negligible heterogeneity, whereas the FDG uptake intensity (I2 = 42.2%) and SUVmax (I2 = 42.1%) methods showed moderate heterogeneity. The pooled sensitivity for FDG uptake intensity was 0.90 (95% confidence interval [CI], 0.79-0.96); for uptake pattern, 0.94 (95% CI, 0.89-0.97); and for SUVmax, 0.95 (95% CI, 0.76-0.99). The pooled specificity for FDG uptake intensity was 0.59 (95% CI, 0.38-0.78); for FDG uptake pattern, 0.81 (95% CI, 0.71-0.88); and for SUVmax, 0.77 (95% CI, 0.63-0.87). The uptake pattern interpretation method demonstrated the best positive and negative post-test probability, 82% and 10%, respectively. CONCLUSIONS: This meta-analysis identified the FDG uptake pattern as the most accurate assessment method of 18F-FDG PET/CT for diagnosis of VGEI. The optimal SUVmax cutoff, depending on the vendor, demonstrated strong sensitivity and moderate specificity.

Diagnostic Imaging in Vascular Graft Infection: A Systematic Review and Meta-Analysis.

BACKGROUND: Vascular graft infection (VGI), a serious complication in vascular surgery, has a high morbidity and mortality rate. The diagnosis is complicated by non-specific symptoms and challenged by the variable accuracy of different imaging techniques. The objective of this study was to determine the diagnostic value of various imaging techniques to diagnose VGI. METHODS: A systematic review was conducted according to the PRISMA guidelines. Data sources included PubMed/Medline, Embase, and Cochrane from January 1997 until October 2017. Observational cohort studies were included. A meta-analysis was conducted on several imaging modalities: computed tomography with or without angiography (CT(A)), 18F-fluoro-d-deoxyglucose positron emission tomography with or without low dose or contrast enhanced CT (FDG-PET(/CT)), and white blood cell scintigraphy with or without single photon emission computed tomography combined with low dose CT (WBC (SPECT/CT)). RESULTS: Of 4259 papers, 14 articles were included, containing eight prospective and six retrospective articles. CTA (I2 7.4%), FDG-PET (I2 36.5%), and FDG-PET/CT (I2 36.6%) showed negligible to moderate heterogeneity, while WBC scintigraphy ± SPECT/CT (I2 78.6%) showed considerable heterogeneity. Pooled sensitivity for CTA was 0.67 (95% CI 0.57-0.75), in contrast to FDG-PET of 0.94 (95% CI 0.88-0.98), FDG-PET/CT of 0.95 (95% CI 0.87-0.99), WBC scintigraphy of 0.90 (95% CI 0.85-0.94), and WBC scintigraphy with SPECT/CT of 0.99 (95% CI 0.92-1.00). The pooled specificities were for CTA 0.63 (95% CI 0.48-0.76), FDG-PET 0.70 (95% CI 0.59-0.79), FDG-PET/CT 0.80 (95% CI 0.69-0.89), WBC scintigraphy 0.88 (95% CI 0.81-1.94), and WBC scintigraphy SPECT/CT 0.82 (95% CI 0.57-0.96). Pre- and post-test results showed that WBC SPECT/CT favours FDG-PET/CT, with a positive post-test probability of 96% versus 83%. CONCLUSION: This meta-analysis suggests the diagnostic performance of WBC scintigraphy combined with SPECT/CT is the greatest in diagnosing VGI. However, it is a time consuming technique and not always available. Therefore FDG-PET/CT may be favourable as the initial imaging technique. The use of solitary CTA in diagnosing VGI seems to be obsolete.

Comparison of midterm results for the Talent and Endurant stent graft.

OBJECTIVE: Stent graft evolution is often addressed as a cause for improved outcomes of endovascular aneurysm repair for patients with an abdominal aortic aneurysm. In this study, we directly compared the midterm result of Endurant stent graft with its predecessor, the Talent stent graft (both Medtronic, Santa Rosa, Calif). METHODS: Patient treated from January 2005 to December 2010 in a single tertiary center in The Netherlands with a Talent or Endurant stent graft were eligible for inclusion. Ruptured abdominal aortic aneurysms or patients with previous aortic surgery were excluded. The primary end point was the Kaplan-Meier estimated freedom from secondary interventions. Secondary end points were perioperative outcomes and indications for secondary interventions. RESULTS: In total, 221 patients were included (131 Endurant and 90 Talent). At baseline, the median aortic bifurcation was narrower for the Endurant (30 mm vs 39 mm; P < .001). Median follow-up was 64.1 ± 37.9 months and 59.2 ± 25.3 months for Talent and Endurant, respectively. The estimated freedom from secondary interventions at 30 days, 1 year, 5 years, and 7 years was 94.3%, 89.4%, 72.2%, and 64.1% for Talent and 96.8%, 89.3%, 75.2%, and 69.2% for Endurant (P = .528). The indication for secondary interventions does differ; more patients required an intervention for a proximal neck-related complication (type Ia endoleak or migration) in the Talent group (18.2% vs 4.8%; P = .001), whereas more interventions for iliac limb stenosis were seen in the Endurant group (0.0% vs 4.8%; P = .044). In a binomial regression analysis, suprarenal angulation, infrarenal neck length, and type of stent graft were independent predictors of neck-related complications. CONCLUSIONS: Evolution from the Talent stent graft into the Endurant has resulted in significant reduction of infrarenal neck-related complications; on the other hand, iliac interventions increased. The overall midterm secondary intervention rate was comparable.

Textural features of 18F-fluorodeoxyglucose positron emission tomography scanning in diagnosing aortic prosthetic graft infection.

BACKGROUND: The clinical problem in suspected aortoiliac graft infection (AGI) is to obtain proof of infection. Although 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography scanning (PET) has been suggested to play a pivotal role, an evidence-based interpretation is lacking. The objective of this retrospective study was to examine the feasibility and utility of 18F-FDG uptake heterogeneity characterized by textural features to diagnose AGI. METHODS: Thirty patients with a history of aortic graft reconstruction who underwent 18F-FDG PET/CT scanning were included. Sixteen patients were suspected to have an AGI (group I). AGI was considered proven only in the case of a positive bacterial culture. Positive cultures were found in 10 of the 16 patients (group Ia), and in the other six patients, cultures remained negative (group Ib). A control group was formed of 14 patients undergoing 18F-FDG PET for other reasons (group II). PET images were assessed using conventional maximal standardized uptake value (SUVmax), tissue-to-background ratio (TBR), and visual grading scale (VGS). Additionally, 64 different 18F-FDG PET based textural features were applied to characterize 18F-FDG uptake heterogeneity. To select candidate predictors, univariable logistic regression analysis was performed (α = 0.16). The accuracy was satisfactory in case of an AUC > 0.8. RESULTS: The feature selection process yielded the textural features named variance (AUC = 0.88), high grey level zone emphasis (AUC = 0.87), small zone low grey level emphasis (AUC = 0.80), and small zone high grey level emphasis (AUC = 0.81) most optimal for distinguishing between groups I and II. SUVmax, TBR, and VGS were also able to distinguish between these groups with AUCs of 0.87, 0.78, and 0.90, respectively. The textural feature named short run high grey level emphasis was able to distinguish group Ia from Ib (AUC = 0.83), while for the same task the TBR and VGS were not found to be predictive. SUVmax was found predictive in distinguishing these groups, but showed an unsatisfactory accuracy (AUC = 0.75). CONCLUSION: Textural analysis to characterize 18F-FDG uptake heterogeneity is feasible and shows promising results in diagnosing AGI, but requires additional external validation and refinement before it can be implemented in the clinical decision-making process.

Modest utility of quantitative measures in (18)F-fluorodeoxyglucose positron emission tomography scanning for the diagnosis of aortic prosthetic graft infection.

BACKGROUND: The clinical dilemma in suspected aortic graft infection (AGI) is how to noninvasively obtain a reliable proof of infection. In addition to confirming the presence of infection, obtaining information regarding the extent of infection to select a proper strategy for reoperation is also necessary. Therefore, developing a more reliable noninvasive physiologic approach to detect infected prostheses is required. (18)F-fluorodeoxyglucose positron emission tomography scanning ((18)F-FDG PET) has been suggested to have a pivotal role in the detection of AGI. In this study, we assessed the contribution of two (semi) quantitative parameters-maximal standardized uptake value (SUVmax) and tissue-to-background ratio (TBR)-and of two visual parameters-fluorodeoxyglucose (FDG) distribution patterns and visual grading scale-in the final confirmation of the diagnosis of AGI. METHODS: Patients with a central aortic prosthetic graft and symptoms clinically suggestive of AGI were gathered from a prospectively maintained database. Included were those who underwent (18)F-FDG PET scanning combined with computed tomography angiography and in whom periprosthetic samples were taken at some stage in the diagnostic process. AGI was considered proven in case of a positive culture and compared with a group with negative cultures. Positive predictive values (PPVs) and negative predictive values (NPVs) were calculated. Receiver operating characteristics curves were used to assess the ability of SUVmax and TBR to identify the presence and absence of AGI (ie, accuracy). RESULTS: In 37 of 77 patients with suspected AGI, (18)FDG-PET and perigraft material for culturing was obtained. The tissue culture was positive in 21 of these 37 patients (56.7%). Mean ± standard deviation SUVmax for proven infection was 8.1 ± 3.7 (range, 3.6-18.5) and TBR was 5.9 ± 2.7 (range, 1.7-13.0). The area under the curve for SUVmax was 0.78 (95% confidence interval, 0.63-0.93). A cutoff value of 8 yielded a PPV of 80% and a NPV of 54%. The area under the curve for TBR was 0.70 (95% confidence interval, 0.52-0.87). A cutoff value of 6 yielded a PPV of 73% and NPV of 52%. The PPVs for the visual grading scale and (18)F-FDG distribution patterns were 75% and 61%, respectively; the NPVs were 77% and 67%, respectively. CONCLUSIONS: Our study, performed in a small sample of patients suspected of AGI, showed that the diagnostic abilities of quantitative and visual (18)F-FDG PET parameters are modest.

Long-Term Survival and Quality of Life After Fenestrated Endovascular Repair for Complex Abdominal Aortic Aneurysms.

OBJECTIVES: Fenestrated endovascular repair (FEVAR) has become a widely used treatment option for complex abdominal aortic aneurysms (AAA) but long-term survival and quality of life (QoL) outcomes are scarce. This single center cohort study aims to evaluate both long-term survival and QoL after FEVAR. METHODS: All juxtarenal and suprarenal AAA patients treated with FEVAR in a single-center between 2002 and 2016 were included. QoL scores, measured by the RAND 36-Item Short Form Survey (SF-36), were compared with baseline data of the SF-36 provided by RAND. RESULTS: A total of 172 patients were included at a median follow-up of 5.9 years (IQR 3.0-8.8). Follow-up at 5 and 10 years post-FEVAR yielded survival rates of 59.9% and 18%, respectively. Younger patient age at surgery had a positive influence on 10-year survival and most patients died due to cardiovascular pathology. Emotional well-being was better in the research group as compared to baseline RAND SF-36 1.0 data (79.2 ± 12.4 vs 70.4 ± 22.0; P < 0.001). Physical functioning (50 (IQR 30-85) vs 70.6 ± 27.4; P = 0.007) and health change (51.6 ± 17.0 vs 59.1 ± 23.1; P = 0.020) were worse in the research group as compared to reference values. CONCLUSIONS: Long-term survival was 60% at 5-years follow-up, which is lower than reported in recent literature. An adjusted positive influence of younger age at surgery was found on long-term survival. This could have consequences for future treatment indication in complex AAA surgery but further large-scale validation is necessary.

Added Value of Abnormal Lymph Nodes Detected with FDG-PET/CT in Suspected Vascular Graft Infection.

Vascular graft and endograft infections (VGEI) cause a serious morbidity and mortality burden. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) imaging is frequently used in the diagnostic workup, but the additional value of abnormal (18F-FDG active and/or enlarged) locoregional lymph nodes is unknown. In this retrospective study, the additional diagnostic value of abnormal locoregional lymph nodes on 18F-FDG PET/CT imaging for VGEI was evaluated, including 54 patients with a culture-proven VGEI (defined according to the Management of Aortic Graft Infection [MAGIC] group classification) and 25 patients without VGEI. 18F-FDG PET/CT was qualitatively and quantitatively assessed for tracer uptake and pattern at the location of the vascular graft, and locoregional lymph node uptake and enlargement (>10 mm). 18F-FDG uptake intensity and pattern independently predicted the presence of VGEI by logistic regression (Χ2: 46.19, p < 0.001), with an OR of 7.38 (95% CI [1.65, 32.92], p = 0.009) and 18.32 (95% CI [3.95, 84.88], p < 0.001), respectively. Single visual assessment of abnormal locoregional lymph nodes predicted the presence of VGEI with a sensitivity of 35%, specificity of 96%, PPV of 95%, and NPV of 41%. The visual assessment of abnormal lymph nodes after qualitative assessment of 18F-FDG uptake intensity and pattern at the vascular graft location did not independently predict the presence of VGEI by logistic regression (Χ2: 3.60, p = 0.058; OR: 8.25, 95% CI [0.74, 63.37], p = 0.096). In conclusion, detection of abnormal locoregional lymph nodes on 18F-FDG PET/CT has a high specificity (96%) and PPV (95%) for VGEI. However, it did not add to currently used 18F-FDG PET/CT interpretation criteria.

Diagnosis and treatment of vascular graft and endograft infections: a structured clinical approach.

A vascular graft or endograft infection (VGEI) is a severe complication that can occur after vascular graft or endograft surgery and is associated with high morbidity and mortality rates. A multidisciplinary approach, consisting of a team of vascular surgeons, infectious diseases specialists, medical microbiologists, radiologists, nuclear medicine specialists, and hospital pharmacists, is needed to adequately diagnose and treat VGEI. A structured diagnostic, antibiotic, and surgical treatment algorithm helps clinical decision making and ultimately aims to improve the clinical outcome of patients with a VGEI.