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Hu Q, Huang Z, Zhang H, Ma P, Feng R, Feng J. Coaxial electrospun Ag-NPs-loaded endograft membrane with long-term antibacterial function treating mycotic aortic aneurysm. Mater Today Bio 2024; 25:100940. [PMID: 38298561 PMCID: PMC10827516 DOI: 10.1016/j.mtbio.2023.100940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/23/2023] [Accepted: 12/30/2023] [Indexed: 02/02/2024] Open
Abstract
The use of endovascular stent-graft has become an important option in the treatment of aortic pathologies. However, the currently used endograft membranes have limited ability to prevent bacterial colonization. This makes them unsuitable for the treatment of mycotic aneurysms, as the infection is prone to progress after endograft implantation. Moreover, even in non-mycotic aortic pathologies, endograft infections can occur in the short or long term, especially for patients with diabetes mellitus or in immune insufficiency conditions. So, this study aimed to develop a kind of Ag-NPs-loaded endograft membrane by coaxial electrospinning technique, and a series of physical and chemical properties and biological properties of the Ag-NPs-loaded membrane were characterized. Animal experiments conducted in pigs confirmed that the Ag-NPs-loaded membrane was basically non-toxic, exhibited good biocompatibility, and effectively prevented bacterial growth in a mycotic aortic aneurysm model. In conclusion, the Ag-NPs-loaded membrane exhibited good biocompatibility, good anti-infection function and slow-release of Ag-NPs for long-term bacteriostasis. Thus, the Ag-NPs-loaded membrane might hold potential for preventing infection progression and treating mycotic aortic aneurysms in an endovascular way.
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Affiliation(s)
- Qingxi Hu
- Rapid Manufacturing Engineering Center, School of Mechatronic Engineering and Automation, Shanghai University, Shanghai, 200444, China
- Shanghai Key Laboratory of Intelligent Manufacturing and Robotics, Shanghai University, Shanghai, 200072, China
- National Demonstration Center for Experimental Engineering Training Education, Shanghai University, Shanghai, 200444, China
| | - Zhenwei Huang
- Rapid Manufacturing Engineering Center, School of Mechatronic Engineering and Automation, Shanghai University, Shanghai, 200444, China
| | - Haiguang Zhang
- Rapid Manufacturing Engineering Center, School of Mechatronic Engineering and Automation, Shanghai University, Shanghai, 200444, China
- Shanghai Key Laboratory of Intelligent Manufacturing and Robotics, Shanghai University, Shanghai, 200072, China
- National Demonstration Center for Experimental Engineering Training Education, Shanghai University, Shanghai, 200444, China
| | - Pengcheng Ma
- Department of Vascular Surgery, Changhai Hospital, Naval Medical University, Shanghai, 200433, China
| | - Rui Feng
- Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Jiaxuan Feng
- Vascular surgery department, Ruijin Hospital, affiliated to Medical school of Shanghai Jiaotong University, Shanghai, PR China
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2
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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Sunnerhagen T, Schwartz F, Christophersen L, Bjarnsholt T, Qvortrup K, Eldrup N, Vogt K, Moser C. Biofilm formation on endovascular aneurysm repair (EVAR) grafts-a proof of concept in vitro model. Clin Microbiol Infect 2023; 29:1600.e1-1600.e6. [PMID: 37734593 DOI: 10.1016/j.cmi.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 08/11/2023] [Accepted: 09/14/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVES An endovascular aneurysm repair (EVAR) graft is a catheter-implanted vascular prosthesis and is the preferred treatment for patients with aortic aneurysm. If an EVAR graft becomes the focus of infection, the treatment possibilities are limited because it is technically difficult to remove the graft to obtain source control. This study examines whether Pseudomonas aeruginosa and Staphylococcus aureus form biofilm on EVAR prostheses. METHODS EVAR graft sections were exposed to bacteria at 102 or 108 colony forming units (CFU)/mL in lysogeny broth and Krebs-Ringer at 37°C, bacterial biofilm formation was evaluated by scanning electron microscopy and counting CFU on the graft sections after antibiotic exposure at × 10 minimal inhibitory concentration. Bacteria were tested for tolerance to benzylpenicillin, tobramycin, and ciprofloxacin. RESULTS Bacterial exposure for 15 minutes established biofilms on all prosthesis fragments (6/6 replicates). After 4 hours, bacteria were firmly attached to the EVAR prostheses and resisted washing. After 18-24 hours, the median CFU/g of EVAR graft reached 5.2 × 108 (1.15 × 108-1.1 × 109) for S. aureus and 9.1 × 107 (3.5 × 107-6.25 × 108) for P. aeruginosa. Scanning electron microscopy showed bacterial attachment to the graft pieces. There was a time-dependent development of tolerance with approximately 20 (tobramycin), 560 (benzylpenicillin), and 600 (ciprofloxacin) times more S. aureus surviving antibiotic exposure in 24- compared with 0-hour-old biofilm. Five (tobramycin) and 170 times (ciprofloxacin) more P. aeruginosa survived antibiotic exposure in 24- compared with 0-hour-old biofilms. DISCUSSION Our results show that bacteria can rapidly adhere to and subsequently form antibiotic-tolerant biofilms on EVAR graft material in concentrations equivalent to levels seen in transient bacteraemia in vivo. Potentially, the system can be used for identifying optimal treatment combinations for infected EVAR prosthesis.
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Affiliation(s)
- Torgny Sunnerhagen
- Department of Clinical Microbiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark; Division for Infection Medicine, Department for Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden; Clinical Microbiology and Infection Control, Office for Medical Services, Region Skåne, Lund, Sweden.
| | - Franziska Schwartz
- Department of Clinical Microbiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Christophersen
- Department of Clinical Microbiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas Bjarnsholt
- Department of Clinical Microbiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark; Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Klaus Qvortrup
- Department of Biomedical Sciences, Core Facility for Integrated Microscopy, University of Copenhagen, Copenhagen, Denmark
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Katja Vogt
- Department of Vascular Surgery, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Claus Moser
- Department of Clinical Microbiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark; Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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4
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Kim YW. Aortic Endograft Infection: Diagnosis and Management. Vasc Specialist Int 2023; 39:26. [PMID: 37732343 PMCID: PMC10512004 DOI: 10.5758/vsi.230071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/18/2023] [Accepted: 08/28/2023] [Indexed: 09/22/2023] Open
Abstract
Aortic endograft infection (AEI) is a rare but life-threatening complication of endovascular aneurysm repair (EVAR). The clinical features of AEI range from generalized weakness and mild fever to fatal aortic rupture or sepsis. The diagnosis of AEI usually depends on clinical manifestations, laboratory tests, and imaging studies. Management of Aortic Graft Infection Collaboration (MAGIC) criteria are often used to diagnose AEI. Surgical removal of the infected endograft, restoration of aortic blood flow, and antimicrobial therapy are the main components of AEI treatment. After removing an infected endograft, in situ aortic reconstruction is often performed instead of an extra-anatomic bypass. Various biological and prosthetic aortic grafts have been used in aortic reconstruction to avoid reinfection, rupture, or occlusion. Each type of graft has its own merits and disadvantages. In patients with an unacceptably high surgical risk and no evidence of an aortic fistula, conservative treatment can be an alternative. Treatment results are determined by bacterial virulence, patient status, including the presence of an aortic fistula, and hospital factors. Considering the severity of this condition, the best strategy is prevention. When encountering a patient with AEI, current practice emphasizes a multidisciplinary team approach to achieve an optimal outcome.
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Affiliation(s)
- Young-Wook Kim
- Division of Vascular Surgery, Department of Surgery, Incheon Sejong Hospital, Incheon, Korea
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5
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Gavali H, Mani K, Furebring M, Olsson KW, Lindström D, Sörelius K, Sigvant B, Torstensson G, Andersson M, Forssell C, Åstrand H, Lundström T, Khan S, Sonesson B, Stackelberg O, Gillgren P, Isaksson J, Kragsterman B, Gidlund KD, Horer T, Sadeghi M, Wanhainen A. Semi-Conservative Treatment Versus Radical Surgery in Abdominal Aortic Graft and Endograft Infections. Eur J Vasc Endovasc Surg 2023; 66:397-406. [PMID: 37356704 DOI: 10.1016/j.ejvs.2023.06.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 04/30/2023] [Accepted: 06/19/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE Abdominal aortic graft and endograft infections (AGIs) are rare complications following aortic surgery. Radical surgery (RS) with resection of the infected graft and reconstruction with extra-anatomical bypass or in situ reconstruction is the preferred therapy. For patients unfit for RS, a semi-conservative (SC), graft preserving strategy is possible. This paper aimed to compare survival and infection outcomes between RS and SC treatment for AGI in a nationwide cohort. METHODS Patients with abdominal AGI related surgery in Sweden between January 1995 and May 2017 were identified. The Management of Aortic Graft Infection Collaboration (MAGIC) criteria were used for the definition of AGI. Multivariable regression was performed to identify factors associated with mortality. RESULTS One hundred and sixty-nine patients with surgically treated abdominal AGI were identified, comprising 43 SC (14 endografts; 53% with a graft enteric fistula [GEF] in total) and 126 RS (26 endografts; 50% with a GEF in total). The SC cohort was older and had a higher frequency of cardiac comorbidities. There was a non-significant trend towards lower Kaplan-Meier estimated five year survival for SC vs. RS (30.2% vs. 48.4%; p = .066). A non-significant trend was identified towards worse Kaplan-Meier estimated five year survival for SC patients with a GEF vs. without a GEF (21.7% vs. 40.1%; p = .097). There were significantly more recurrent graft infections comparing SC with RS (45.4% vs. 19.3%; p < .001). In a Cox regression model adjusting for confounders, there was no difference in five year survival comparing SC vs. RS (HR 1.0, 95% CI 0.6 - 1.5). CONCLUSION In this national AGI cohort, there was no mortality difference comparing SC and RS for AGI when adjusting for comorbidities. Presence of GEF probably negatively impacts survival outcomes of SC patients. Rates of recurrent infection remain high for SC treated patients.
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Affiliation(s)
- Hamid Gavali
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Mia Furebring
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Karl Wilhelm Olsson
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - David Lindström
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Karl Sörelius
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Birgitta Sigvant
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Vascular Surgery, Karlstad Central Hospital, Karlstad, Sweden
| | - Gustav Torstensson
- Department of Surgery, Helsingborg Regional Hospital, Helsingborg, Sweden
| | - Manne Andersson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Surgery, County Hospital Ryhov, Ryhov, Jönköping County, Sweden
| | - Claes Forssell
- Department of Cardiovascular Surgery, Division of Vascular Surgery, Linköping University Hospital, Linköping, Sweden
| | - Håkan Åstrand
- Department of Surgery, County Hospital Ryhov, Ryhov, Jönköping County, Sweden
| | - Tobias Lundström
- Department of Surgery and Urology, Eskilstuna Hospital, Eskilstuna, Sweden
| | - Shahzad Khan
- Department of Surgery, Malmö University Hospital, Lund University, Malmö, Sweden
| | - Björn Sonesson
- Department of Surgery, Malmö University Hospital, Lund University, Malmö, Sweden
| | - Otto Stackelberg
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden; Unit of Cardiovascular and Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Peter Gillgren
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Södersjukhuset, Stockholm, Sweden
| | - Jon Isaksson
- Department of Surgical and Peri-operative Sciences, Umeå University, Umeå, Sweden
| | - Björn Kragsterman
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Surgery, Västerås Central Hospital, Västerås, Sweden
| | - Khatereh Djavani Gidlund
- Department of Cardiothoracic and Vascular Surgery and Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery and Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mitra Sadeghi
- Department of Cardiothoracic and Vascular Surgery and Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Surgical and Peri-operative Sciences, Umeå University, Umeå, Sweden
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Hosaka A, Kumamaru H, Usune S, Miyata H, Goto H. Surgical Repair of Abdominal Aorto-Iliac Prosthetic Graft Infections: A Nationwide Japanese Cohort Study. Eur J Vasc Endovasc Surg 2023; 66:407-416. [PMID: 37391011 DOI: 10.1016/j.ejvs.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 05/23/2023] [Accepted: 06/23/2023] [Indexed: 07/02/2023]
Abstract
OBJECTIVE Prosthetic graft infection (PGI) after open abdominal aortic and iliac artery reconstruction is life threatening. However, because it is rare and frequently difficult to diagnose, robust evidence on its treatment and optimal management strategies are lacking. This study aimed to clarify the clinical characteristics and surgical treatment outcomes of this condition and to identify pre-operative and operative factors affecting its prognosis. METHODS This was a nationwide cohort study. Using a nationwide clinical registry system, patients who were treated surgically for PGI after open abdominal aortic and iliac artery reconstruction between 2011 and 2017 were investigated, and their profiles and clinical courses were analysed. The relationships between the pre-operative and operative factors and the post-operative outcomes, including death and persistent or recurrent graft related infection, were evaluated. RESULTS The study included 213 patients. The median duration between the index arterial reconstruction and surgical treatment for PGI was 644 days. Fistula development to the gastrointestinal tract was confirmed during surgery in 53.1% of patients. The cumulative overall survival rates at 30 and 90 days, one, three, and five years were 87.3%, 74.8%, 62.2%, 54.5%, and 48.1%, respectively. Pre-operative shock was the only factor independently associated with 90 day and three year death. Short term and late mortality rates, as well as the rate of persistent or recurrent graft related infection, did not differ significantly between patients treated with total removal of the infected graft and those treated with partial removal of the graft. CONCLUSION Surgery for PGI after open reconstruction of the abdominal aorta and iliac arteries is complex, and the post-operative mortality rate remains high. Partial removal of the infected graft may be an alternative in selected patients with limited extent of infection.
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Affiliation(s)
- Akihiro Hosaka
- Department of Vascular Surgery, Tokyo Metropolitan Tama Medical Centre, Tokyo, Japan; Japanese Society for Vascular Surgery, Tokyo, Japan.
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shiyori Usune
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hitoshi Goto
- Japanese Society for Vascular Surgery, Tokyo, Japan; Department of Vascular Surgery, South Miyagi Medical Centre, Miyagi, Japan
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Colacchio EC, D'Oria M, Grando B, Rinaldi Garofalo A, D'Andrea A, Bassini S, Lepidi S, Antonello M, Ruaro B. A Systematic Review of In-situ Aortic Reconstructions for Abdominal Aortic Graft and Endograft Infections: Outcomes of Currently Available Options for Surgical Replacement. Ann Vasc Surg 2023; 95:307-316. [PMID: 37023924 DOI: 10.1016/j.avsg.2023.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/17/2023] [Accepted: 03/22/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND This review synthetizes recent literature about in-situ aortic reconstructions for abdominal aortic graft or endograft infections (AGEIs), aiming to report outcomes individually related to currently available vascular substitutes (VSs). METHODS We performed a systematic review of all published literature from January 2005 to December 2022. We included articles reporting on open surgical treatment of abdominal AGEIs, with removal of the infected graft and in-situ reconstruction with biological or prosthetic material. Articles not distinguishing between abdominal and thoracic aortic-related outcomes were excluded, as well as studies reporting on cumulative in-situ and extra-anatomic reconstruction results. RESULTS Of 500 records identified through database searching (Pubmed: 226; Embase: 274), 8 of them were included in the present review. Overall, 30-days mortality rate was 8.7% (25/285), while the most frequent early complications were respiratory adverse events (46/346, 13.3%) and renal function deterioration (26/85, 30%). In 250/350 cases (71.4%), a biological VS was utilized. In 4 articles, the outcomes of different types of VSs were presented jointly. Patients analyzed in the remaining 4 reports were sorted in a "biological" and a "prosthetic" group (BG and PG). The cumulative mortality rate of the BG and PG were 15.6% (33/212) and 27% (9/33), respectively, while graft reinfection was 6.3% (15/236) in the BG, and 9% (3/33) in the PG. The cumulative mortality rate reported in articles focused on autologous veins was 14.8% (30/202), while their 30-days reinfection rate was 5.7% (13/226). CONCLUSIONS Since abdominal AGEIs are uncommon conditions, literature focused on direct comparison between different types of VSs is scarce, particularly when related to materials other than autologous veins. Although we found a lower overall mortality rate in patients treated with biological material or with autologous veins only, in recent reports prosthesis provide promising results in terms of mortality and reinfection rate. However, none of the available studies distinguish and compares different types of prosthetic material. Large multicenter studies are advisable, especially focused on different types of VSs and their comparison.
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Affiliation(s)
- Elda Chiara Colacchio
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Vascular and Endovascular Surgery Clinic, School of Medicine, Padova University, Padova, Italy.
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara, University of Trieste, Trieste, Italy
| | - Beatrice Grando
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Vascular and Endovascular Surgery Clinic, School of Medicine, Padova University, Padova, Italy; Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara, University of Trieste, Trieste, Italy
| | - Alessandra Rinaldi Garofalo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Vascular and Endovascular Surgery Clinic, School of Medicine, Padova University, Padova, Italy
| | - Alessia D'Andrea
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Vascular and Endovascular Surgery Clinic, School of Medicine, Padova University, Padova, Italy; Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara, University of Trieste, Trieste, Italy
| | - Silvia Bassini
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara, University of Trieste, Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara, University of Trieste, Trieste, Italy
| | - Michele Antonello
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Vascular and Endovascular Surgery Clinic, School of Medicine, Padova University, Padova, Italy
| | - Barbara Ruaro
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, Trieste, Italy
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8
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Ljungquist O, Haidl S, Dias N, Sonesson B, Sörelius K, Trägårdh E, Ahl J. Conservative Management First Strategy in Aortic Vascular Graft and Endograft Infections. Eur J Vasc Endovasc Surg 2023; 65:896-904. [PMID: 36921753 DOI: 10.1016/j.ejvs.2023.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 01/08/2023] [Accepted: 03/07/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVE The aim of this study was to describe and present the outcomes of a specific treatment protocol for aortic vascular graft and endograft infections (VGEIs) without explantation of the infected graft. METHODS This was a retrospective, observational single centre cohort study carried out between 2012 and 2022 at a tertiary hospital. An aortic VGEI was defined according to the Management of Aortic Graft Infection Collaboration (MAGIC) criteria. Fitness for graft excision was assessed by a multidisciplinary team and included an evaluation of the patient's general condition, septic status, and anatomical complexity. Antimicrobial treatments were individualised. The primary outcome was survival at the last available follow up; secondary outcomes were antimicrobial treatment duration, infection eradication, treatment failure despite antimicrobial treatment, and the development of aortic fistulation. RESULTS Fifty patients were included in the study, of whom 42 (84%) had had previous endovascular repair. The median patient age was 72 years (range 51 - 82 years) and median duration of treatment with antimicrobials was 18 months (range 1 - 164 months). Kaplan-Meier analysis estimated the 30 day survival to be 98% (95% confidence interval [CI] 96 - 100), the one year survival rate to be 88% (95% CI 83.4 - 92.6), and the three year survival rate to be 79% (95% CI 72.7 - 84.7). Twenty-four (48%) patients were able to discontinue antibiotic treatment after a median of 16 months (range 4 - 81 months). When categorised according to infected graft location, deaths occurred in four (40%) patients with thoracic, two (40%) with paravisceral, seven (30%) with infrarenal VGEIs, and in one (25%) patient with an aorto-iliac VGEI; no (0%) patient with a thoraco-abdominal VGEI died. CONCLUSION Identifying the microbiological aetiology in patients with aortic VGEI enables individualised, specific antibiotic treatment, which may be useful in patients with a VGEI excluded from surgery. This single centre retrospective analysis of patients with VGEIs without fistula selected for conservative treatment suggests that conservative management of aortic VGEIs with targeted antibiotic therapy without graft excision is potentially effective, and that antimicrobial treatment will not necessarily be needed indefinitely.
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Affiliation(s)
- Oskar Ljungquist
- Clinical Infection Medicine, Department of Translational Medicine, Faculty of Medicine, Lund University, Malmö, Sweden.
| | - Sven Haidl
- Clinical Infection Medicine, Department of Translational Medicine, Faculty of Medicine, Lund University, Malmö, Sweden; Department of Infectious Diseases, Skåne University Hospital, Malmö, Sweden
| | - Nuno Dias
- Vascular Centre Malmö-Lund, Skåne University Hospital, Malmö, Sweden
| | - Björn Sonesson
- Vascular Centre Malmö-Lund, Skåne University Hospital, Malmö, Sweden
| | - Karl Sörelius
- Clinical Infection Medicine, Department of Translational Medicine, Faculty of Medicine, Lund University, Malmö, Sweden
| | - Elin Trägårdh
- Department of Medical Imaging and Physiology, Skåne University Hospital, Malmö, Sweden
| | - Jonas Ahl
- Clinical Infection Medicine, Department of Translational Medicine, Faculty of Medicine, Lund University, Malmö, Sweden; Department of Infectious Diseases, Skåne University Hospital, Malmö, Sweden
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9
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Infection of Vascular Prostheses: A Comprehensive Review. PROSTHESIS 2023. [DOI: 10.3390/prosthesis5010012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Vascular graft or endograft infection (VGEI) is a complex disease that complicates vascular-surgery and endovascular-surgery procedures and determines high morbidity and mortality. This review article provides the most updated general evidence on the pathogenesis, prevention, diagnosis, and treatment of VGEI. Several microorganisms are involved in VGEI development, but the most frequent one, responsible for over 75% of infections, is Staphylococcus aureus. Specific clinical, surgical, radiologic, and laboratory criteria are pivotal for the diagnosis of VGEI. Surgery and antimicrobial therapy are cornerstones in treatment for most patients with VGEI. For patients unfit for surgery, alternative treatment is available to improve the clinical course of VGEI.
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10
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Omran S, Gröger S, Shafei B, Schawe L, Bruder L, Haidar H, Greiner A. Outcomes of Candida and Non-Candida Aortic Graft Infection. Vasc Endovascular Surg 2023; 57:97-105. [PMID: 36148827 PMCID: PMC9846377 DOI: 10.1177/15385744221129236] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To evaluate and compare the outcomes of Candida- and non-Candida-associated aortic graft infections. METHODS We retrospectively analyzed the data from patients treated for aortic graft infection from 2015 to 2021 in our hospital. RESULTS A total of 66 patients (56 men; median age, 69 years; range, 50-87 years) were admitted with aortic graft infection, including 21 (32%) patients in the Candida group and 45 (68%) in the non-Candida group. The average time between initial operation and presentation of aortic graft infection was 50 months (range, 1-332 months). Graft-enteric fistulas (GEFs) were more often in the Candida group (57% vs 27%, P = .017). The most proven causative fungal specimen was C. albicans in 16 (76%) patients. Non-albicans Candida was found in 9% of all patients and 29% of the Candida patients. The median ICU length of stay was longer in the Candida group than non-Candida (10 vs 9 days, P = .012). Additionally, the median hospital length of stay was longer in the Candida group (33 vs 22 days, P = .048). There were no statistically significant differences between Candida and non-Candida groups according to the in-hospital mortality (24% vs 24%, P = .955), and 1-year mortality (38% vs 38%, P = .980). CONCLUSIONS Patients with bacterial and fungal aortic graft infections have high rates of morbidity and mortality. We found no significant differences in postoperative morbidity and mortality between Candida and non-Candida patients. However, the ICU and hospital length of stay were longer in the Candida group.
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Affiliation(s)
- Safwan Omran
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany,Safwan Omran, Department of Vascular
Surgery, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu
Berlin, and Berlin Institute of Health, Charité––Universitätsmedizin Berlin,
Hindenburgdamm 30, Berlin 12203, Germany.
| | - Steffen Gröger
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany
| | - Bashaer Shafei
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany
| | - Larissa Schawe
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany
| | - Leon Bruder
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany
| | - Haidar Haidar
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany
| | - Andreas Greiner
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany
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11
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Wouthuyzen-Bakker M, van Oosten M, Bierman W, Winter R, Glaudemans A, Slart R, Toren-Wielema M, Tielliu I, Zeebregts CJ, Prakken NHJ, de Vries JP, Saleem BR. Diagnosis and treatment of vascular graft and endograft infections: a structured clinical approach. Int J Infect Dis 2023; 126:22-27. [PMID: 36375692 DOI: 10.1016/j.ijid.2022.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/09/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - Marleen van Oosten
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Wouter Bierman
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Rik Winter
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Andor Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Riemer Slart
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Marlous Toren-Wielema
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ignace Tielliu
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Niek H J Prakken
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jean Paul de Vries
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ben R Saleem
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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12
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Janko MR, Hubbard G, Back M, Shah SK, Pomozi E, Szeberin Z, DeMartino R, Wang LJ, Crofts S, Belkin M, Davila VJ, Lemmon GW, Wang SK, Czerny M, Kreibich M, Humphries MD, Shutze W, Joh JH, Cho S, Behrendt CA, Setacci C, Hacker RI, Sobreira ML, Yoshida WB, D'Oria M, Lepidi S, Chiesa R, Kahlberg A, Go MR, Rizzo AN, Black JH, Magee GA, Elsayed R, Baril DT, Beck AW, McFarland GE, Gavali H, Wanhainen A, Kashyap VS, Stoecker JB, Wang GJ, Zhou W, Fujimura N, Obara H, Wishy AM, Bose S, Smeds M, Liang P, Schermerhorn M, Conrad MF, Hsu JH, Patel R, Lee JT, Liapis CD, Moulakakis KG, Farber MA, Motta F, Ricco JB, Bath J, Coselli JS, Aziz F, Coleman DM, Davis FM, Fatima J, Irshad A, Shalhub S, Kakkos S, Zhang Q, Lawrence PF, Woo K, Chung J. In-situ Bypass Is Associated with Superior Infection-free Survival Compared to Extra-Anatomic Bypass for the Management of Secondary Aortic Graft Infections Without Enteric Involvement. J Vasc Surg 2022; 76:546-555.e3. [PMID: 35470015 DOI: 10.1016/j.jvs.2022.03.869] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/27/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The optimal revascularization modality following complete resection of aortic graft infection (AGI) without enteric involvement remains unclear. The purpose of this investigation is to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients undergoing complete excision of AGI. METHODS A retrospective, multi-institutional study of AGI from 2002-2014 was performed using a standardized database. Baseline demographics, comorbidities, and perioperative variables were recorded. The primary outcome was infection-free survival. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariable analyses were performed. RESULTS 241 patients at 34 institutions from 7 countries presented with AGI during the study period (median age 68 years; 75% male). The initial aortic procedures that resulted in AGI were 172 surgical grafts (71%) and 66 endografts (27%) and 3 unknown (2%). 172 (71%) of the patients underwent complete excision of infected aortic graft material followed by in situ (in-line) bypass (ISB), including antibiotic-treated prosthetic graft (35%), autogenous femoral vein (NAIS) (24%), and cryopreserved allograft (41%). 69 patients (29%) underwent extra-anatomic bypass (EAB). Overall median Kaplan-Meier (KM) estimated survival was 5.8 years. Perioperative mortality was 16%. When stratified by ISB versus EAB, there was a significant difference in KM estimated infection-free survival (2910 days, IQR 391, 3771 versus 180 days, IQR 27, 3750 days; p<0.001). There were otherwise no significant differences in presentation, comorbidities, nor perioperative variables. Multivariable Cox regression showed lower infection-free survival among patients with EAB (HR 2.4, 95% CI 1.6-3.6; p<0.001), polymicrobial infection (HR 2.2, 95% CI 1.4-3.5; p=0.001), MRSA infection (HR 1.7, 95% CI 1.1-2.7; p=0.02), as well as the protective effect of omental/muscle flap coverage (HR 0.59, 95% CI 0.37-0.92; p=0.02). CONCLUSIONS After complete resection of AGI, perioperative mortality is 16% and median overall survival is 5.8 years. EAB is associated with nearly a two-and-half fold higher re-infection/mortality compared to ISB. Omental and/or muscle flap coverage of the repair appear protective.
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Affiliation(s)
- Matthew R Janko
- Division of Vascular Surgery and Endovascular Therapy, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Grant Hubbard
- Division of Vascular Surgery and Endovascular Therapy, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Martin Back
- Division of Vascular Surgery, Department of Surgery, University of Florida, Gainesville, FL
| | - Samir K Shah
- Division of Vascular Surgery, Department of Surgery, University of Florida, Gainesville, FL
| | - Eniko Pomozi
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Zoltan Szeberin
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Randall DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Linda J Wang
- Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Sarah Crofts
- Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Michael Belkin
- Department of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Victor J Davila
- Division of Vascular Surgery, Department of General Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Gary W Lemmon
- Division of Vascular Surgery, Department of Surgery, Indiana University, Indianapolis, IN
| | - Shihuan K Wang
- Division of Vascular Surgery, Department of Surgery, Indiana University, Indianapolis, IN
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen, Freiburg, Germany
| | - Misty D Humphries
- Division of Vascular Surgery, Department of Surgery, UC Davis Health, Sacramento, CA
| | - William Shutze
- Texas Vascular Associates, The Heart Hospital Plano, Plano, TX
| | - Jin Hyun Joh
- Division of Vascular Surgery, Department of Surgery, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
| | - Sungsin Cho
- GermanVasc Research Group, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian-Alexander Behrendt
- GermanVasc Research Group, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carlo Setacci
- Department of Vascular and Endovascular Surgery, University of Siena, Sienna, Italy
| | - Robert I Hacker
- Division of Vascular Surgery, Surgical Arts of St. Louis, Bridgeton, MO
| | - Marcone Lima Sobreira
- Department of Surgery and Orthopedics, Botucatu School of Medicine, Paulista State University, São Paulo, Brazil
| | - Winston Bonetti Yoshida
- Department of Surgery and Orthopedics, Botucatu School of Medicine, Paulista State University, São Paulo, Brazil
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Trieste, Italy
| | - Roberto Chiesa
- Department of Vascular Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Kahlberg
- Department of Vascular Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Michael R Go
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - Anthony N Rizzo
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Ramsey Elsayed
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Donald T Baril
- Division of Vascular Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Hamid Gavali
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Wanhainen
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Jordan B Stoecker
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Wei Zhou
- Division of Vascular Surgery, Department of Surgery, University of Arizona, Tucson, AZ
| | - Naoki Fujimura
- Department of Surgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Andrew M Wishy
- Division of Vascular and Endovascular Surgery, Brooke Army Medical Center, San Antonio, TX
| | - Saideep Bose
- Division of Vascular Surgery, Department of Surgery, Saint Louis University, St Louis, MO
| | - Matthew Smeds
- Division of Vascular Surgery, Department of Surgery, Saint Louis University, St Louis, MO
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mark F Conrad
- Division of Vascular Surgery, St Elizabeth's Hospital, Brighton, MA
| | - Jeffrey H Hsu
- Division of Vascular Surgery, Kaiser Permanente, Fontana, CA
| | - Rhusheet Patel
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Jason T Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Christos D Liapis
- Department of Vascular Surgery, Attikon University Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos G Moulakakis
- Department of Vascular Surgery, Attikon University Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Fernando Motta
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers Medical School, Poitiers, France
| | - Jonathan Bath
- Cardiovascular Surgical Clinics, University of Missouri, Columbia, MO
| | - Joseph S Coselli
- Division of Vascular Surgery, Penn State Health Heart and Vascular Institute, Hershey, PA
| | - Faisal Aziz
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Dawn M Coleman
- MedStar Heart and Vascular Institute, Georgetown University, Washington, DC
| | - Frank M Davis
- MedStar Heart and Vascular Institute, Georgetown University, Washington, DC
| | - Javairiah Fatima
- Cardiovascular Center at Tufts Medical Center, Tufts University School of Medicine, Boston, MA
| | - Ali Irshad
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | - Sherene Shalhub
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | - Stavros Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Qianzi Zhang
- Division of Vascular and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Peter F Lawrence
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Karen Woo
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Jayer Chung
- Division of Vascular and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
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