Xavier Berard (Bordeaux, France) gave delegates at the 2019 Charing Cross Symposium (CX; 15–18 April, London, UK) three fundamental principles to bear in mind when dealing with aortic graft infections using an open approach.
He advised the audience to first of all plan their surgical strategy, analysing the computed tomography angiogram (CTA) in the same way as for an endovascular aneurysm repair (EVAR). Additionally, he suggested total graft excision rather than partial removal and to step the clamping frame.
Berard also said that he preferred to use a biological approach wherever possible, but to adopt an antimicrobial (Synergy, Getinga) graft in cases where extensive repair is required. He cautioned against using rifampicin on prostheses, having already outlined its disadvantages when used as monotherapy, in which situation it promotes the development of resistant strains, and also because it is not a wide spectrum antibiotic and it lacks antifungal activity.
Finally, and “most importantly”, Berard emphasised the need to create a multidisciplinary team approach. This should consist of nuclear medicine physicians, infectious disease specialists, microbiologists, anaesthetists and vascular surgeons working together to identify the best solution for each individual patient, based on their past medical history, and their current clinical status. The team should decide issues such as whether preoperative percutaneous drainage is necessary to decrease the microorganism load, what revascularisation technique should be used, and the length of follow-up that will be required.
Berard outlined how Bordeaux University has evolved its approach over time to reflect these three principles, and the impact this has had on their reinfection rates. Analysis of 2004–2011 data versus data collected between 2011 and 2018 observed a declining trend in the reinfection rate, from 47.6% to 12.5% (p=0.004), which he attributed to the adoption of the changed strategy. The percentage of enteric fistulae also decreased, from 61.3% in the years between 2004 and 2011, to 50.8% from 2011–2018.