Episode 110
110: StAR: Vascular Graft Infections
This StAR episode features the CID State-of-the-Art Review on a comprehensive approach to vascular graft infection.
Our guest stars this episode are:
Hussam Tabaja
Supavit “Mac” Chesdachai
Daniel DeSimone
(from Mayo Clinic, Rochester, Minnesota)
Journal companion article - Executive summary link: https://academic.oup.com/cid/article/78/6/1391/7651000
From Clinical Infectious Diseases
Episodes | Consult Notes | Subscribe | Twitter | Merch | febrilepodcast@gmail.com
Febrile is produced with support from the Infectious Diseases Society of America (IDSA)
Transcript
Hey everyone, welcome to Febrile, a cultured podcast about all things infectious disease.
Sara Dong:We use consult questions to dive into ID clinical reasoning, diagnostics, and antimicrobial management.
Sara Dong:I'm Sara Dong, your host and a MedPeds ID doc.
Sara Dong:We're back with a Febrile StAR episode.
Sara Dong:Today, we have a team all from the Division of Public Health, Infectious Diseases, and Occupational Medicine at Mayo Clinic in Rochester, Minnesota.
Sara Dong:So let me introduce our guest stars.
Sara Dong:First up, we have Dr.
Sara Dong:Hussam Tabaja, who is an assistant professor of medicine in the Division of ID.
Sara Dong:He completed his internal medicine residency at the Detroit Medical Center and Wayne State University.
Sara Dong:Following that, he moved to Rochester, where he completed his three year ID fellowship at Mayo Clinic.
Sara Dong:His clinical research is focused on hardware associated infections, including both cardiovascular device and orthopedic device infections.
Hussam Tabaja:Hi, my name is Hussam Tabaja.
Hussam Tabaja:I am very excited to be here today.
Sara Dong:Next, we welcome Dr.
Sara Dong:Mac Chesdachai.
Sara Dong:He is an assistant professor of medicine in the Division of I.
Sara Dong:D.
Sara Dong:He completed his internal medicine residency at the University of Minnesota followed by his fellowship at Mayo Clinic.
Sara Dong:His interests include cardiovascular infections and infections in solid organ transplant recipients.
Mac Chesdachai:Hi, my name is Mac Chesdachai.
Mac Chesdachai:Thank you so much for having me.
Sara Dong:And rounding out the team is Dr.
Sara Dong:Daniel DeSimone.
Sara Dong:He is a consultant and associate professor in the Division of ID.
Sara Dong:He also holds a joint appointment in the Department of Cardiovascular Diseases.
Sara Dong:He has chaired and vice chaired several American Heart Association scientific statements in cardiovascular infectious diseases.
Sara Dong:His clinical and research interests focus on the prevention, diagnosis, and management of infective endocarditis, cardiac implantable electronic device infections, and vascular graft infections.
Daniel DeSimone:Hi, my name is Daniel DeSimone, and it's a pleasure to be here.
Sara Dong:Great.
Sara Dong:So before we talk about your paper, I'd like to ask, as everyone's favorite cultured podcast, I'd love to hear a little piece of culture, basically just something non medical that has made you happy recently.
Hussam Tabaja:So yeah, I mean, I consider myself a boring individual, so not too many interesting things have been going on.
Hussam Tabaja:One interesting thing I've recently been playing pickleball, with Mac actually, and, uh, it's very new.
Hussam Tabaja:I've never actually, uh, knew about this sport before just a couple of months ago.
Hussam Tabaja:So that's, that's a new activity.
Hussam Tabaja:And I think it's interesting.
Sara Dong:Someone, someone else mentioned pickleball recently.
Sara Dong:I'm not actually sure if it's been released, but you're in good company.
Hussam Tabaja:Yeah.
Hussam Tabaja:Mac is a pro.
Hussam Tabaja:I am a beginner.
Sara Dong:What about you, Mac?
Mac Chesdachai:Apart from playing pickleball with Hussam, actually one thing that I just want to share is that I'm from Thailand and then in Thai culture.
Mac Chesdachai:I mean, the reason why my name is Mac is just because my parents gave me Mac as a nickname.
Mac Chesdachai:And I just, I learned that all Thai people always has a nickname because their name is very complicated.
Mac Chesdachai:And then the Mac is just from MacGyver, the series that my parents love.
Sara Dong:Excellent.
Daniel DeSimone:And I loved MacGyver growing up.
Daniel DeSimone:So that's incredible.
Daniel DeSimone:I didn't know that.
Mac Chesdachai:I, I, I never watched this actually.
Mac Chesdachai:So
Daniel DeSimone:it's a classic.
Sara Dong:I know it's one of those references that I think is starting to fade.
Sara Dong:Like people maybe don't know, but.
Sara Dong:That's a good nickname.
Daniel DeSimone:I love that.
Daniel DeSimone:I grew up on that show.
Daniel DeSimone:And, you know, I never got that pickleball invite, so, uh, you know, but something that brings me joy is I love grilling and I've taken up doing a lot of smoking, not, not cigarettes or anything like that.
Daniel DeSimone:That's unhealthy.
Daniel DeSimone:Don't smoke.
Daniel DeSimone:Smoking ribs.
Daniel DeSimone:That's kind of been something I've done over the last, not so much in the winter here because it gets quite cold in Rochester, but definitely in the spring, summer, late fall, and fall I've gotten into trying smoking on my grill and you got these little smoker tubes and you can get different pellets and it's just like a whole nother subculture that like, I just got into it's dangerous.
Daniel DeSimone:It's a rabbit hole, but it's fun.
Daniel DeSimone:And, uh, I'm Italian.
Daniel DeSimone:So we enjoy, we enjoy eating and we enjoy watching people eat.
Daniel DeSimone:That's just my Italian call.
Daniel DeSimone:That's what my Nana used to do is she would just make food and watch us eat.
Daniel DeSimone:So I have that same passion.
Sara Dong:That sounds very good.
Sara Dong:Well, I am excited to have you guys here.
Sara Dong:This is one of our StAR episodes, so we're talking about the state of the art reviews.
Sara Dong:And you guys created, along with your colleagues, a review article on vascular graft infections.
Sara Dong:And so I thought I'd actually start by opening up to give you an opportunity to just introduce the topic and actually the terminology because I think that sometimes the use of graft infection can be a bit broad and interpreted differently by various people.
Sara Dong:So yeah, would you guys introduce us to the topic?
Hussam Tabaja:Yeah, sure.
Hussam Tabaja:So I can take this actually and make two introductory points that I think will be important.
Hussam Tabaja:So the first one is, what do we mean by vascular graft infection in this paper?
Hussam Tabaja:And that will help clarify the patients that we think this review will apply to.
Hussam Tabaja:And the second point is, what is the purpose and what are we trying to achieve through this review?
Hussam Tabaja:So, to the first point, if I will give you a simple definition, it'll be an infection of a vascular graft used for vascular reconstruction.
Hussam Tabaja:But of course, like you said, vascular reconstruction is a very broad terminology, so we need to be a bit more specific.
Hussam Tabaja:In this review, what we are focusing on is an infection of any graft material, whether biologic or synthetic, that is used to repair arterial aneurysms or pseudoaneurysms through either an endovascular approach or an open surgical approach that involves arteries both intracavitary and extracavitary.
Hussam Tabaja:In that definition, what I did is I actually defined five different aspects that I think are very important to help specify the patient.
Hussam Tabaja:So we are saying that this review will focus and will be relative to both graft material types, which broadly there are two different graft materials.
Hussam Tabaja:There is a biologic and synthetic.
Hussam Tabaja:We are saying that this is going to be specifically about arteries, not veins.
Hussam Tabaja:The pathology will be specifically aneurysms and pseudoaneurysms.
Hussam Tabaja:This does not relate to hemodialysis graft, for example.
Hussam Tabaja:We are saying that this document is relative to both surgical techniques.
Hussam Tabaja:There are two different surgical techniques for vascular reconstruction, so both endovascular and open surgical, and this review will apply to that, and the last point is that we're covering both the intracavitary and the extracavitary arteries.
Hussam Tabaja:And I think it's also important to clarify this further.
Hussam Tabaja:So intracavitary means that the artery is inside a cavity, like an abdomen or a chest, and extracavitary means that the artery is outside.
Hussam Tabaja:So it could be in the groin, in the thigh, in the leg.
Hussam Tabaja:For this review specifically, we are including the entire arterial tree and arterial system, but we are excluding ascending aortas because ascending aortas are unique.
Hussam Tabaja:They have different ways to diagnose and to manage, and so they do not fit in this review.
Hussam Tabaja:This review is talking about the rest of the arterial system.
Hussam Tabaja:So that's to point number one.
Hussam Tabaja:Uh, point number two is what are we trying to achieve in this review?
Hussam Tabaja:What we want to do is we want to describe a model of care that we think institutions can apply in order to ensure effective prevention, diagnosis, and management of vascular graft infection.
Hussam Tabaja:And we are hoping to do that through the clinical vignettes that we're going to be discussing in this podcast.
Hussam Tabaja:The central theme for this model of care is the multidisciplinary collaboration.
Hussam Tabaja:If you look at the graphic abstract, we actually have a picture of a vascular graft infection and there is a ring around it.
Hussam Tabaja:And on the ring, there are some bubbles or circles, and within those circles, we have listed different healthcare personnel or hospital teams that we think have an essential role in providing high quality care for the patient.
Hussam Tabaja:So this is a very important collaborative network in order to be able to actually care for those patients.
Hussam Tabaja:We need a lot of resources.
Hussam Tabaja:This is a very complex condition.
Hussam Tabaja:If you look at those circles, there are three that are highlighted with dark blue compared to the others which are light blue.
Hussam Tabaja:So these three are the patient, the vascular surgeon, and the infectious disease provider.
Hussam Tabaja:What we are trying to say here is that this collaborative network is put together, guided, and directed by those three, but it is a team effort, and so if any other members are missing, neither the vascular surgeon nor the infectious disease doctor will be able to provide high quality care for the patient.
Hussam Tabaja:This is a very important point in this paper, and it brings me to one point that we actually make at the very end, which is for a center to be able to provide this good or high quality care for the patient, they have to have minimum capabilities.
Hussam Tabaja:If they don't, then it's very important that this patient be transferred to a center that has all of these substantial and very important resources for providing high quality care for this patient.
Hussam Tabaja:So this will be kind of an overview of what we're trying to do here in this paper.
Sara Dong:That's been a common theme across all these reviews is thinking about the multidisciplinary teams.
Sara Dong:I'm glad you emphasized that right up front.
Sara Dong:So yeah, we're going to talk about a couple clinical stories to chat about vascular graft infections.
Sara Dong:So we'll meet our first patient.
Sara Dong:We have a 60 year old man who has a 6 centimeter abdominal aortic aneurysm.
Sara Dong:He is evaluated by vascular surgery for elective endovascular arterial repair.
Sara Dong:The patient is a tobacco smoker and has a history of diabetes, hypertension, and stage 2 CKD.
Sara Dong:He reports a childhood allergy to penicillin.
Sara Dong:In this pre op setting, what evaluations do we need to think about to help mitigate both his risk of surgical site infection and or vascular graft infection?
Daniel DeSimone:This case is a classic case, something that providers or frontline clinicians are going to encounter in folks, I don't want to say on a frequent basis, but does come up quite often.
Daniel DeSimone:If you look at this patient in this scenario, they have most of the risk factors that come into play here for vascular graft infection, as well as surgical site infection, so smoking, diabetes, high blood pressure, chronic kidney disease.
Daniel DeSimone:These are all factors that come into play.
Daniel DeSimone:Some other things to consider, again, not this patient, but in addition to what this patient has, malnutrition.
Daniel DeSimone:So the patient's nutritional status, it's something that often is overlooked, but it's an elective procedure.
Daniel DeSimone:If we have time to improve this patient's nutrition, if, if they were malnourished, that's very helpful from a healing standpoint, right?
Daniel DeSimone:So they have to go through the surgery, survive the surgery, but then have to recover.
Daniel DeSimone:And it's during that recovery phase where that wound that does not close or where just the substrate, this patient's substrate just doesn't have the ability to close.
Daniel DeSimone:Well, now you have that open wound, depending on how it was repaired, that's now a potential portal of entry for organisms.
Daniel DeSimone:So that's something that I feel is often overlooked.
Daniel DeSimone:And again, in addition to diabetes, chronic renal disease, if there's underlying malignancy, and peripheral arterial disease.
Daniel DeSimone:So these are some of your major risk factors related to the patient.
Daniel DeSimone:Then you also have to factor in just the perioperative risk factors as well.
Daniel DeSimone:And if you take a look at figure four in our document, you'll see we have this all kind of laid out nicely pre op, intra op, and post op things to consider.
Daniel DeSimone:One thing to consider is if we can prevent vascular graft infections, that's always preferred than having to have to treat vascular graft infections.
Daniel DeSimone:So there are some preventative measures we can take and in this patient, in this scenario, we have the luxury of time.
Daniel DeSimone:So this is an elective endovascular arterial repair.
Daniel DeSimone:So there's several things we can do pre-op to optimize this patient for surgery and hope to prevent vascular graft infection.
Daniel DeSimone:And some of these things listed here could be in the, as I mentioned earlier about malnutrition, ensuring this patient is nutritional and functional optimization.
Daniel DeSimone:And we talked about the multidisciplinary team.
Daniel DeSimone:So this is something where possibly endocrinology or nutritionist evaluation may be helpful if we have the time.
Daniel DeSimone:If there's any ongoing or active infection, let's say they had a diabetic foot ulcer or something like that, that'd be something you'd want to manage or optimize as best as possible.
Daniel DeSimone:Diabetes, making sure their glucose control is under as tight of control as possible, particularly leading up to surgery.
Daniel DeSimone:Also, one thing in this patient's history, which comes up a lot, is this childhood allergy to penicillin.
Daniel DeSimone:So when this person was a child, you know, they got a penicillin or amoxicillin, and their, and their mother said, you know, never take penicillin again, you're allergic to it, and now it's 70 years later.
Daniel DeSimone:And sure enough, a lot of data actually out of our institution, as well as others, looked at that classic history of penicillin allergy and found that that really was not a true allergy in that.
Daniel DeSimone:You know, many of these patients, we've avoided any sort of penicillin or beta lactam based therapies.
Daniel DeSimone:A lot of data out there that shows giving beta lactams prior to surgery, it does much better compared to non beta lactam therapy like vancomycin.
Daniel DeSimone:So IV cefazolin prior to surgical incision has a much better rate of preventing surgical site infections, possibly even these leading forward to potential graft infections.
Daniel DeSimone:So this is something where either consultation with an allergist to potentially form penicillin skin testing is something to consider here.
Daniel DeSimone:Although even that practice is starting to change as well to where a history like this oftentimes just giving that one dose in a supervised setting pre op without even seeing allergy, having that skin test being performed, is something that a lot of centers are starting to do.
Daniel DeSimone:So I think that's a nice area that there's a lot of data showing that beta lactam therapy is superior at preventing surgical site infections compared to something like vancomycin.
Daniel DeSimone:Otherwise, at this point, those are probably the best thing.
Daniel DeSimone:So we have the luxury of time.
Daniel DeSimone:Let's use it.
Daniel DeSimone:Let's get this patient as optimized as possible.
Daniel DeSimone:And one more thing, as I mentioned, the tobacco smoking, any way we can prevent that, that will be not, not just for surgical site infection, vascular graft infection, as well as, you know, downstream, all the complications from cigarette smoking.
Sara Dong:Some good PSAs, don't smoke, de label your penicillin allergies.
Sara Dong:Excellent.
Sara Dong:So we'll head to our second patient.
Sara Dong:We have a 67 year old woman who is admitted with fever and septic shock due to MSSA bacteremia from an unclear source.
Sara Dong:She has a history of open surgical repair, a abdominal aortic aneurysm with a Dacron graft five months prior to admission, as well as a permanent pacemaker that's been in place for about five years.
Sara Dong:She was started on cefazolin, has stabilized, and has a weaned off of pressors.
Sara Dong:But her Staph aureus bacteremia has persisted now for three days.
Sara Dong:So as ID consultants, we're often called to determine whether the source of Staph aureus bacteremia or really other bloodstream infections can be due to a vascular graft.
Sara Dong:So how should we approach these cases?
Mac Chesdachai:I can take this one.
Mac Chesdachai:As Sara mentioned, it is a very common scenario that we encounter as an ID provider.
Mac Chesdachai:We often get calls about this patient presents with bloodstream infection.
Mac Chesdachai:They have a graft in place, they have a pacemaker in place.
Mac Chesdachai:What do I do with the graft?
Mac Chesdachai:And it's very, very challenging question, not just only for the primary team, but for our infectious disease team as well.
Mac Chesdachai:So when we think about the bloodstream infection in a patient who has a graft in place, we have to think whether the graft itself is a source of bloodstream infection.
Mac Chesdachai:Is that bloodstream infection come from somewhere else and then now infected the graft?
Mac Chesdachai:Or the bloodstream infection has just happened from somewhere else and then now the graft is still okay without infected?
Mac Chesdachai:And sometimes it's very challenging to distinguish all of that.
Mac Chesdachai:Apart from the investigation that we're going to obtain in the near future, we have to think about two factors that play a part in the bloodstream infection.
Mac Chesdachai:The first factor is that what kind of organism causing bloodstream infection.
Mac Chesdachai:For example, from this clinical vignette, the Staph aureus bacteremia.
Mac Chesdachai:As we all know, it's scary.
Mac Chesdachai:I think that this patient is in trouble because she has both pacemaker and vascular graft in place, which just recently placed months ago, which means it's very early.
Mac Chesdachai:So the risk of infection is definitely higher than the patient who present with bacteremia in the later state of the vascular graft placement.
Mac Chesdachai:This patient is in trouble, but it's quite obvious that when the patient present with the Staph aureus bacteremia, we really need to look for something else like, you know, graft infection, pacemaker infection.
Mac Chesdachai:But it might not be obvious in the case that the patient present with other type of bloodstream infection, for example, Gram negative or other Gram positive other than Staph.
Mac Chesdachai:Most of the time, the principle is that Staph aureus bloodstream infection has the highest risk of graft becoming infected.
Mac Chesdachai:On the other hand, when the patient presents with urosepsis and Gram negative bacteremia, the chance of vascular graft becoming infected is relatively low compared to Gram positive.
Mac Chesdachai:There is some in the middle risk.
Mac Chesdachai:For example, in a patient who has like a Strep bloodstream infection, Enterococci, or even some other type of Gram negative like Pseudomonas or Serratia, all of these fall into the middle category, which means we also need other factors to consider.
Mac Chesdachai:For example, whether the bacteremia is prolonged, whether this is a community onset, whether we could not identify any other source, or whether the bacteremia keep persisting even though we start the treatment.
Mac Chesdachai:So if the patient has all of these factors, our thought about vascular graft infection, the chance of vascular graft infection need to be higher, and we also need to think that we should provide more investigation to look for the graft infection specifically.
Mac Chesdachai:And one other point I just want to point out is early detection of the bloodstream infection in this group of patient is very important.
Mac Chesdachai:For example, if we have some mechanism, for example, if the stewardship team or the microbiology team can alert the provider and say that, Hey, this is a bloodstream infection.
Mac Chesdachai:Especially in the setting of the patient has a device or vascular graft, that would be very helpful because I think the early intervention, early infectious disease consult in this scenario, provide benefit in the patient outcome.
Sara Dong:Great.
Sara Dong:So after going through that process, knowing that this patient is high risk for vascular graft infection, you recommend a CTA, which shows perigraft gas and some organized fluid.
Sara Dong:The TEE shows endocarditis.
Sara Dong:So at this point, we have a confirmation of vascular graft infection.
Sara Dong:We call up vascular surgery, who's consulted for graft explantation, along with consulting EP to talk about pacemaker removal and the setting of the Staph aureus bacteremia.
Sara Dong:And so this patient is considered fit for surgical intervention.
Sara Dong:You started to talk about it in the beginning, but what are the types of surgical approaches that are used to try and cure infection?
Hussam Tabaja:I, I like to think about those, uh, scenarios through algorithms.
Hussam Tabaja:And so there is actually an algorithm that we included in this review that discusses surgical approach for intra cavity vascular graft infection.
Hussam Tabaja:I'll talk about it in a minute, but before that, there are some important points to make.
Hussam Tabaja:If you look at intracavitary vascular graft infection, and even extracavitary really, the way I think about the surgical approach is under two umbrellas.
Hussam Tabaja:There is the curative approach, and there is the suppressive approach.
Hussam Tabaja:So curative approach means that you have to explant and remove the entire infected graft.
Hussam Tabaja:It needs to come out.
Hussam Tabaja:This is source control.
Hussam Tabaja:We love this as infectious disease physicians, right?
Hussam Tabaja:We always want source control.
Hussam Tabaja:So that infected graft needs to come out and there needs to be plans for reconstruction because of course you will need to connect the proximal and distal ends again, but for cure, you have to remove the infected graft.
Hussam Tabaja:The suppressive approach is anything other than that.
Hussam Tabaja:So if you are not going to explant the entire graft, you are not going to cure this infection.
Hussam Tabaja:And you can see a lot of different scenarios, right?
Hussam Tabaja:Sometimes that patient does not have any form of surgery, sometimes they have only debridement, sometimes they have partial resection of the graft, but then the other part of the graft is still there.
Hussam Tabaja:So anything outside of explanting the entire graft, in our opinion, is not going to really be a curative approach.
Hussam Tabaja:Now, when you look at the literature, and of course, this is not going to be any high quality studies because vascular graft infection is not a very common condition, so it's not very well studied.
Hussam Tabaja:But if you look at the literature, with the vascular graft explantation, this is a high risk procedure.
Hussam Tabaja:It's a very complex procedure, and mortality can be between 18 percent to 30%, even though as infectious disease providers, we want to advocate for a curative approach, and we always push for that, you know, we're not the ones who are doing the surgery, so we really have to understand the point of
Hussam Tabaja:view of the vascular surgeons who say, you know, this patient is not a good fit for surgery because he's gonna have a very high risk of complication.
Hussam Tabaja:So we really need to be aware of that.
Hussam Tabaja:But if you look at the suppressive approach in the literature there, there is actually some studies that show that mortality 100% after 2 years.
Hussam Tabaja:So, we're saying that if you don't explant the graft and you do a suppressive approach for intracavitary vascular graft infection, specifically intracavitary, this suppressive approach is not a durable option and patients will eventually have a bad outcome.
Hussam Tabaja:If there is any way you could advocate for a curative approach.
Hussam Tabaja:then that should be the way you go about it.
Hussam Tabaja:But at the same time, we have to understand when the surgeons tell us that this patient is particularly at high risk for surgery, and I don't think I can go in and explant the graft for this patient.
Hussam Tabaja:Okay, so that's, those are a couple of points that I wanted to make first.
Hussam Tabaja:Now, if you come to the algorithm that we have, it mainly talks about the curative approach, right?
Hussam Tabaja:So there are two different pathways to explant the graft and do a curative approach.
Hussam Tabaja:Both of these pathways actually include the explantation of the entire graft.
Hussam Tabaja:But what distinguishes those pathways is how you're going to reconstruct after you explant.
Hussam Tabaja:There is something called extra anatomic reconstruction, and there is something called in situ reconstruction.
Hussam Tabaja:What in situ reconstruction means is that they go in, they explant the entire infected graft, they debride, clean, clean, clean, remove everything that looks infected, and then they, within that same surgery, they put in a new graft, whether this is a biologic or a synthetic graft, they put it at the same time.
Hussam Tabaja:Okay?
Hussam Tabaja:This is in situ reconstruction.
Hussam Tabaja:Extranatomic reconstruction means that in the reconstruction, they will bypass the infected field.
Hussam Tabaja:And this is usually done in two stages.
Hussam Tabaja:Stage one, they go in, they form a bypass, and this usually is a synthetic graft for intracavitary VGIs.
Hussam Tabaja:They do a bypass around the infected field, and then they bring the patient back a few days later for the second stage, where they resect the infected graft and debride and clean out the infection.
Hussam Tabaja:They can't do them in the same stage because it will be a very long procedure, it will be a lot of ischemia, and the mortality rate will go up.
Hussam Tabaja:And now in the past, extranatomic reconstruction was kind of the preferred approach by the surgeons.
Hussam Tabaja:But now they are going more towards in situ reconstruction because there's data to show that in situ reconstruction actually has less complications, less mortality, better patency of the new graft, less ischemia, and even some studies showing that there is less recurrence
Hussam Tabaja:of infection, even though it makes sense to think that extra-anatomic will have lower risk because you're bypassing the infected site.
Hussam Tabaja:So these are the two surgical approaches within the curative category.
Hussam Tabaja:And there is no gold standard in the literature.
Hussam Tabaja:It all depends on the case, the anatomy of the vascular graft that's infected, and really the surgeon's preference.
Hussam Tabaja:So as of now, we don't have a gold standard for what surgery should be done over the other.
Hussam Tabaja:Both of them are still being applied until today.
Sara Dong:All right.
Sara Dong:So for this patient, vascular surgery performs graft explantation and in situ reconstruction.
Sara Dong:EP has exchanged the pacemaker and you know, we're ID docs.
Sara Dong:We can dive into antibiotics now.
Sara Dong:What recommendations do you guys have for antimicrobial therapy?
Daniel DeSimone:The surgery is the hard part, no doubt about it, but this is also a big challenge sometimes because number one, hopefully you have accurate microbiological diagnosis.
Daniel DeSimone:That's the first step on our end, because a lot of these patients, okay, somebody like this is septic.
Daniel DeSimone:Well, they started antibiotics.
Daniel DeSimone:Luckily, we knew there was MSSA bacteremia, but let's say they're not septic and blood cultures are negative, or at least at the time of starting antibiotics, blood cultures were negative.
Daniel DeSimone:We have to factor that in.
Daniel DeSimone:So, okay, so accurate microbiological diagnosis is key.
Daniel DeSimone:And before even getting into all that, what is very important here, in addition of, hey, what's the bug, is you have to tailor this.
Daniel DeSimone:You have to individualize this therapy for that patient with that procedure and take all the medical comorbidities into account, take into account the surgical aspect as well.
Daniel DeSimone:As Hussam mentioned earlier, we ideally want cure, right?
Daniel DeSimone:I mean, I think everybody wants cure, but these are major high risk surgeries.
Daniel DeSimone:Every patient in this group will be quite high risk and will be high risk for if they were to relapse or have a recurrence.
Daniel DeSimone:So what I'm getting at here is this seems easy and it's like, oh, well, here's the bug.
Daniel DeSimone:Here's the antibiotic for this long and that's it.
Daniel DeSimone:But I always say have plan A, plan B, plan C, D, E, F in these patients.
Daniel DeSimone:And I say that because what is it, what can go wrong, will go wrong.
Daniel DeSimone:Yeah, so let's put them on IV for six weeks.
Daniel DeSimone:So right up there front, you know, IV six weeks, some cases you may have, you could go oral, but for the most part, these folks are going to be six weeks IV up front.
Daniel DeSimone:And then what do you do after that?
Daniel DeSimone:So after that six weeks of IV antibiotics, the question gets to, do they need to be on some form of suppressive therapy, or in other words, a prophylactic three to six months, and in some cases even up to a year depending on the graft.
Daniel DeSimone:But again, you have to tailor this to the individual.
Daniel DeSimone:You have to take into account their risk of Okay, if this were to relapse or recur, what trouble are they in?
Daniel DeSimone:What did they do at the time of surgery?
Daniel DeSimone:Did they do in situ reconstruction and put a put a graft, a synthetic graft?
Daniel DeSimone:Or did they put a a cryopreserved tissue graft, or do they do an ex anatomic bypass, which is going to be a synthetic?
Daniel DeSimone:Those all factor into do I put this patient on for three to six months?
Daniel DeSimone:Do I put them on a year?
Daniel DeSimone:Do I put them on lifelong?
Daniel DeSimone:And then also the organism.
Daniel DeSimone:So if you have something like Staph aureus, Pseudomonas, multi drug resistant pathogens, you also may consider lifelong prophylactic or suppressive therapy, depending on on how they reconstruct it.
Daniel DeSimone:But you also have to factor in that's not always easy.
Daniel DeSimone:So if you have Pseudomonas, well, what's your, at the, you know, for the most part, what's your oral, what's your only oral option for suppression?
Daniel DeSimone:Cipro or Levo?
Daniel DeSimone:Well, what if they have a prolonged QT?
Daniel DeSimone:Well, that kind of leaves that out.
Daniel DeSimone:Do I put them on, uh, IV gentamicin therapy three times a week?
Daniel DeSimone:I mean, these are things that where I was saying you kind of want to have those backup plans or contingency plans in place because something will go wrong.
Daniel DeSimone:Now this patient in our center, in our scenario here is uh, 67.
Daniel DeSimone:Well what if they're 35?
Daniel DeSimone:Are you going to keep them on lifelong suppression if they're 35 with MSSA?
Daniel DeSimone:Sure, you could try, but at some point, either the patient's going to develop some intolerance or, you know, let's say C.
Daniel DeSimone:diff is a complication or the bug develops resistance and now it became, you know, MRSA.
Daniel DeSimone:Again, I'm just throwing things out there that are possibilities, but, but these are all things you have to take into account.
Daniel DeSimone:So, again, an individualized approach to each patient.
Daniel DeSimone:None of this is a route where you just say, okay, everybody's gonna get this, this, and that's it.
Daniel DeSimone:No, it's, you have to take everything into account.
Daniel DeSimone:Their age, their comorbidities, and actually, this is where you want to do some shared decision making.
Daniel DeSimone:This is where, you know, we talk about the multidisciplinary teams, and again, yeah, we're going to kind of be the deciding factor from an infection side, you know, antibiotics, but the patient's going to have to take this medicine for, let's say we go down the lifelong route, maybe 10, 20 years.
Daniel DeSimone:Do they want to be on a fluoroquinolone for 10 years.
Daniel DeSimone:Can they even tolerate it?
Daniel DeSimone:You know, I mean, these are just things you have to factor in.
Daniel DeSimone:So that's why it's not just one thing out there.
Daniel DeSimone:What we have in figure seven, kind of in the antimicrobial course, realize that this has to be individualized.
Daniel DeSimone:It's not just, just because someone goes for in situ reconstruction with a synthetic graft, that they're all going to get this program.
Daniel DeSimone:I wish it was that easy, but it's actually quite the opposite.
Daniel DeSimone:Cause then the other part to this is, well, how do we, okay, in the hospital, it's quite easy.
Daniel DeSimone:Put them on IV antibiotics, get a PICC line in, set them up with lab monitoring and an OPAT or outpatient antimicrobial therapy monitoring, and we'll see in six weeks.
Daniel DeSimone:Okay.
Daniel DeSimone:Well, what happens at the six week mark?
Daniel DeSimone:And, and, and as I mentioned, having those contingency plans, because there will be some drug drug interactions or side effects or intolerances, and that's, we're having that robust team with pharmacists, nursing, that support in the outpatient setting is critical because once the surgery is done, these patients have
Daniel DeSimone:to recover and hopefully we can either prevent infection from coming back or keep it under control and suppress or hopefully cure and again, we I said the hard part was the surgery, but oftentimes the hard part is getting through those six weeks and then potentially another three to six months of oral prophylaxis or
Daniel DeSimone:potentially lifelong suppression because, as Hussam mentioned a little while ago, some of these these infections carry high morbidity as well as high mortality.
Daniel DeSimone:So, we want to be as aggressive as we can be, but always keep the patient at the center of your decisions and involve them in these decisions.
Daniel DeSimone:discuss with them.
Daniel DeSimone:This is not easy.
Daniel DeSimone:There's not one cookbook recipe that, okay, this works for everybody.
Daniel DeSimone:And I kind of prepare patients that, yeah, this, you know, certain things can fail or, or you may not tolerate it.
Daniel DeSimone:And we have to do certain things that are outside of the box a little bit.
Daniel DeSimone:So keep the patient focused, individualize this, talk with the surgeon.
Daniel DeSimone:What happens if we fail?
Daniel DeSimone:What if it's Pseudomonas and the only thing we have is IV options?
Daniel DeSimone:Is there, what's this patient's chance of another surgical intervention?
Daniel DeSimone:Let's say they went for a suppressive route.
Daniel DeSimone:Perhaps, you know, does this patient need to go for an extra anatomic reconstruction?
Daniel DeSimone:But if you, you know, the surgeon may say that's not possible, you know, it's so high risk, you know, it's not even So these are just things you, you gotta take all this into account because like I said, some of these decisions can be, they're, they're not easy and can be quite complex.
Daniel DeSimone:Multidisciplinary team comes up quite often at this, you know, post surgery, a lot of times it's, it's a lot of discussions, a lot of close follow up to hopefully have, have success for this patient.
Sara Dong:Yeah.
Sara Dong:Those conversations are hard, especially the lifelong suppression and like presenting that to the patient in a way that they can make the decision.
Sara Dong:I mean, that alone is challenging because sometimes describing what the risk first benefit is, it's not, you know, it's not easy to quantify that.
Sara Dong:And I think sometimes patients want that.
Daniel DeSimone:Yeah.
Daniel DeSimone:And I don't think there's a number, right?
Daniel DeSimone:Like it's, and even for that patient, I usually tell my patients a lot of times, it's sometimes it's a, Hey, it's 50 50.
Daniel DeSimone:either it worked or it didn't work for you, right?
Daniel DeSimone:But, uh, you know, overall, the absolute risk may be low, you know, it's lower, but at the same time, for that patient, if it happens to them, yeah, it's not zero.
Daniel DeSimone:It's either going to happen, it's either 50 50 or essentially it works or it doesn't work.
Daniel DeSimone:So yeah, those are tough conversations.
Daniel DeSimone:And again, this is, this is complex to us.
Daniel DeSimone:So us trying to to translate this to our patients, to understand that the gravity of the situation, I think is important to do that because again, well, why do we want to put you on an antibiotic for the rest of your life?
Daniel DeSimone:Well, there's some bad stuff that can happen if we don't.
Daniel DeSimone:But again, just having these discussions throughout the process is very important.
Sara Dong:All right, well, we have one more patient that's coming through.
Sara Dong:This time we have a 65 year old woman who's hospitalized because of pain and swelling in her right thigh.
Sara Dong:She had a percutaneous coronary intervention eight months ago, which is complicated by a large common femoral pseudo aneurysm requiring repair with a polyester graft.
Sara Dong:The ultrasound of the thigh demonstrates an organized fluid collection communicating with the graft.
Sara Dong:The patient is hemodynamically stable, so antibiotics are held.
Sara Dong:The patient goes for a percutaneous aspiration and then from that is shown to have purulent fluid which yielded polymicrobial growth and cultures.
Sara Dong:So vascular surgery and ID are involved.
Sara Dong:How would you talk about approaching this case?
Mac Chesdachai:So when you have a fluid collection around a graft and also you aspirate and it's growing polymicrobial.
Mac Chesdachai:It's definitely not good.
Mac Chesdachai:In this scenario, I don't think the diagnosis is challenging because we know that the extra cavitary graft is involved.
Mac Chesdachai:The more challenging thing that we need to discuss down the road is how to manage this patient.
Mac Chesdachai:That will be the key of this clinical scenario.
Mac Chesdachai:So when we encounter the extra cavitary vascular graft, I usually think about the Samson classification.
Mac Chesdachai:So when we think about the Samson classification, it's divided into like five categories.
Mac Chesdachai:The 1 and 2, skin and soft tissue infection around the graft that is not involved in the graft itself.
Mac Chesdachai:When we talk about the graft infection, we talk about Samson 3, 4, and 5.
Mac Chesdachai:So, 5 is the extreme, which means the patient is septic, has a bleeding, has a bacteremia.
Mac Chesdachai:That's a SAMSON 5.
Mac Chesdachai:And then SAMSON 3 and 4, uh, the category that graft is involved, but it also depends on whether it involves anatomosis or not, that would be SAMSON 3 and 4.
Mac Chesdachai:In this category, I think the patient falls into category of SAMSON 3 and 4, because she has been hemodynamically stable, and we know that there's a fluid collection around the graft.
Mac Chesdachai:So the reason why we want to know about the Samson category, because that would affect our management.
Mac Chesdachai:For example, the, the Samson 1 and Samson 2, we usually do like aggressive debridement with the antibiotic because the infection is not involved in the graft, so we don't need to do any surgical approach.
Mac Chesdachai:But when we talk about the Samson 3, 4, and 5, that's when the graft involvement, that's the reason why we also have a thought process the same way as the Sampson 1.
Mac Chesdachai:When we're dealing with the intracavitary, which means are we doing surgical management, like for curative purpose, or we do the suppressive strategy, which I think the thought is the same.
Mac Chesdachai:So when we talk about the SAMSON 3 and 4, we can either do debridement with preserve the graph, or we can do the debridement plus doing the surgical approach to exchange the graft, and then all of that, most of the time, the patient like this will need multiple debridement and muscle flap and prolonged antibiotic course, the same as Hussam and Dan mentioned.
Mac Chesdachai:Let's say if the patient has like Samson 3 and 4 and they have like the easy to treat organism, sometimes the vascular surgeon will do the graft preservation, which means doing multiple debridement.
Mac Chesdachai:Plus the antibiotic therapy for, you know, four to six weeks of IV followed by the oral suppression for three to six months in when we run into the easy to treat organism.
Mac Chesdachai:When I say the easy to treat, mean the organism that is not fall into the category of, you know, Staph aureus, MRSA, Pseudomonas, or MDRO, or the multi drug resistant organism.
Mac Chesdachai:All of those most of the time we will need a surgical approach to, you know, remove the graft and exchange and everything like that, followed by the prolonged antibiotic therapy.
Mac Chesdachai:And again, this kind of case is very, very complicated, even with the infectious disease itself.
Mac Chesdachai:So I think it is very important to involve multidisciplinary team.
Mac Chesdachai:As Hussam mentioned that we are not the one who, you know, actually do the surgery.
Mac Chesdachai:So we need to talk to the expert in this scenario and come up with a multidisciplinary conclusion to say that, okay, this patient may be suitable for this approach.
Mac Chesdachai:This patient may need graft preservation, followed by the antibiotic, which requires multiple discussion and also multiple factor that need to take part in the discussion.
Mac Chesdachai:And also, I think the patient preference is also the one that sometimes we, we didn't involve them because we think that, okay, we managed this after Samson 3, 4, 5.
Mac Chesdachai:And when we talk to the patient, sometimes the patient say that, no, I don't want anything done or something like that.
Mac Chesdachai:So I think patient centered decision is also very important in this situation.
Sara Dong:And in addition to talking about multidisciplinary care, another key theme of a lot of these state of the art reviews is health disparities.
Sara Dong:And I was wondering if you could give a little insight into that related to vascular graft infection.
Hussam Tabaja:Yes.
Hussam Tabaja:So, you know, as, as expected, you're not going to, uh, find a lot of literature specific to vascular graft infection when it comes to healthcare disparities, but we know a lot about social determinants of health and healthcare disparities from other complex conditions.
Hussam Tabaja:And you know, it makes sense to think that they all apply here in vascular graft infection.
Hussam Tabaja:What we can do and what we have done in the paper is we listed at least one that we think is a very important factor, uh, where disparities could be seen.
Hussam Tabaja:I'm hoping now towards the end of the podcast between myself, Dan, and Mac, we have already kind of highlighted the just extensive resources needed to take care of the patient.
Hussam Tabaja:Itv truly needs like a village.
Hussam Tabaja:What's the saying?
Hussam Tabaja:Need a village to take care, to raise a child.
Hussam Tabaja:It needs a village to take care of the patient as well.
Hussam Tabaja:We have, you know, if you look at the review, we have mentioned almost everyone in the hospital and how everyone can have a role.
Hussam Tabaja:We talked about surgeons, physicians, including specialists, and including hospitalists.
Hussam Tabaja:We talked about social workers, nurses, pharmacists, OPAT, antimicrobial stewardship, and microbiology labs.
Hussam Tabaja:So really extensive resources.
Hussam Tabaja:And so do we expect that every hospital has those resources available?
Hussam Tabaja:Of course not.
Hussam Tabaja:There are certain centers that are able to provide this type of service.
Hussam Tabaja:And so, the disparity here is access to this care, right?
Hussam Tabaja:There is a lot of reasons why some patients might not be able to access this care.
Hussam Tabaja:For example, your zip code, right?
Hussam Tabaja:It's just a simple, you know, idea, right?
Hussam Tabaja:The zip code of the patient can actually determine whether or not this patient is able to get access to the specialized care because not everyone lives somewhere that has a big hospital next to them that's able to do things like that.
Hussam Tabaja:Access to specialized care is very, very important and, you know, how do we centralize this care?
Hussam Tabaja:How do we refer those patients immediately or as soon as possible to those big centers?
Hussam Tabaja:That is actually the trick.
Hussam Tabaja:That is one of the major health care disparity and we kind of spoke again about the minimum capabilities that a center has to have in order to provide care.
Hussam Tabaja:If that's not available, then really there should be efforts made to transfer the patient soon enough to a larger hospital.
Hussam Tabaja:I can give you more examples about things that I think are important in this patient population.
Hussam Tabaja:If you think about it, this is again a very complex condition and it actually requires a lot from the patient himself.
Hussam Tabaja:You know, if you go back to that graphic abstract, we said that the patient was one of those three bubbles that was highlighted with dark blue because they really need to, to steer the ship.
Hussam Tabaja:They need to be engaged in their care.
Hussam Tabaja:They need to know what's going on.
Hussam Tabaja:There is going to be a lot of treatment plans, follow up labs, and all of that.
Hussam Tabaja:So the patient really needs to know what's going on.
Hussam Tabaja:And so you think about patient education, you think about patient language barrier, and those things are additional stuff that could come in the way, right?
Hussam Tabaja:And I think You know, unfortunately, as physicians become more and more busy, I don't think that we are making, you know, we're not, we're doing a good job educating those patients properly.
Hussam Tabaja:You know, physicians need to know that they need to give them more time.
Hussam Tabaja:There should be an interpreter.
Hussam Tabaja:And even if the interpreter is with you in the room, you need to repeat what you've been saying to the patient.
Hussam Tabaja:You need to give, just give them more time, make sure that they understand what's going on before they get out of the hospital and that there is a way for them to actually follow up with the care teams.
Hussam Tabaja:So these are kind of some of the things that I can think of and that we have observed when we've taken care of those patients.
Hussam Tabaja:Everything else that we know about social determinants of health and how they affect other complex conditions will probably also be applied applicable to, to vascular graft infections.
Sara Dong:Well, we're approaching the end.
Sara Dong:To wrap up, I also like to leave a little space just to see if there are key take homes that you want to emphasize and or adding something that you think that is important that we didn't quite get a chance to touch on.
Hussam Tabaja:We kind of mentioned briefly that there is not too much literature about vascular graft infection and it may, one of the reasons is because it's not very common.
Hussam Tabaja:Now, this is important to also state that it is not common, but you know, as it's just like any other surgery.
Hussam Tabaja:As the surgical cases increase, which they are, we know that more and more people are undergoing those procedures, we are going to see more and more infections or infection cases.
Hussam Tabaja:And we are already seeing that in referral centers.
Hussam Tabaja:We, we see a lot of vascular graft infections.
Hussam Tabaja:So, and those are likely going to increase.
Hussam Tabaja:So, I think we have to make all efforts that we can in order to talk more about this topic so that physicians are more aware of it.
Hussam Tabaja:This is one of the reasons why we were even interested in making such a review, to kind of describe this topic because we think that it's going to be become more prevalent in the future as more and more patients undergo those procedures.
Mac Chesdachai:Now because we are dealing with aging population, so more and more people will undergo both of the pacemaker and vascular graft and everything like that.
Mac Chesdachai:So we're going to see this more and more.
Mac Chesdachai:I would like to encourage everyone to, to read our paper.
Mac Chesdachai:Most of the time when I get a consult on vascular graft infection, I am not the only one that can manage the patient.
Mac Chesdachai:I need to talk to multiple people and I would encourage when we get consult about this very complex scenario, talk to your colleagues, talk to other people who often see this condition because I think it's very, very complicated and require, you know, the whole village to take care of the patient.
Mac Chesdachai:One last thing is that I just want to also shout out to the co author who helped writing this paper, who didn't join the podcast this morning.
Mac Chesdachai:Our paper also involves collaborative effort from pharmacy, from vascular surgery, from multiple people who helped writing this paper, I just want to say thank you to all of them.
Daniel DeSimone:One last thing to take home from, from my standpoint would be, understand that the landscape of vascular graft surgery and vascular approach to these aneurysms are changing.
Daniel DeSimone:And it's been changing over the last decade or so.
Daniel DeSimone:And what, what do I mean by that?
Daniel DeSimone:A lot of these aneurysms are now being replaced via endovascular repair rather than open surgical repair.
Daniel DeSimone:And that changes.
Daniel DeSimone:the landscape quite a bit.
Daniel DeSimone:So, instead of having a big, large incision
Daniel DeSimone:midline, now this can be performed with an incision in the groin region.
Daniel DeSimone:So, instead of having these big, large incisions where the risk of the surgery definitely goes up, I mean, as I said, all these vascular surgery interventions are high risk, but open surgical repair versus endovascular repair has revolutionized this process of aneurysm repair.
Daniel DeSimone:So what do I mean by that?
Daniel DeSimone:Why do I say that?
Daniel DeSimone:Is patients that may have been deemed too high risk, too sick to go for open surgical repair, are now being considered for endovascular repair.
Daniel DeSimone:So think of this in the realm of TAVR, transcatheter arterial valve repair, where some patients were too high risk to go for open cardiac surgery, but they're not too sick to replace a valve through the patient's wrist or through the groin region.
Daniel DeSimone:Compare that to vascular repair, even in emergent cases, as well as elective cases.
Daniel DeSimone:Patients, as well as surgeons are starting to opt more towards endovascular repair compared to open surgical repair, which also opens up, broadens the pool of folks who would have been deemed, as I mentioned, too high risk or too sick to go for aneurysm repair, open surgical repair, who are now, you know, the risk is not that high to where they can undergo endovascular repair.
Daniel DeSimone:So, so what happens there is you have patients with higher medical comorbidities, or air quotes, sicker.
Daniel DeSimone:So the population is changing.
Daniel DeSimone:So as Hussam mentioned, we're going to see more vascular graft infections, and I think he's right on that, but I will say that we do see a lower rate of graft infections with endovascular repair or replacement versus open surgical repair.
Daniel DeSimone:However, that pool of patients with more comorbidities, the worry there would be, yes, even though the procedure itself has a lower risk of infection and the grafts that are repaired that way have a lower risk.
Daniel DeSimone:However, the patient and their comorbidities being so high that changing in the pool risk could potentially lead to an increased infection.
Daniel DeSimone:But again, that's what the, we'll see where things are in the next five to 10 years and on that, but, but I think Hussam is correct in that regard.
Daniel DeSimone:So that's something else to keep in mind is that the surgical approach has changed.
Daniel DeSimone:Therefore the pool or population is, is going to change as well.
Daniel DeSimone:And ultimately, you know, I think if anything you've heard us say is throughout this podcast is individualized approach.
Daniel DeSimone:Each patient come up with a plan with not just yourself, with a, with a multidisciplinary team of what's best for your patient at that moment in time and be flexible, involve them in the decision making, keep them in the center of that decision.
Daniel DeSimone:In the end, that doing what's best for the patient, I think that's the best route here.
Sara Dong:Well, you guys can come back in a couple of years and update us on how it's evolving.
Sara Dong:Well, thank you guys for joining.
Daniel DeSimone:Sara, thank you so much for having us.
Daniel DeSimone:Greatly appreciate it.
Sara Dong:Thanks again to Hussam, Mac, and Daniel for joining Febrile today.
Sara Dong:You can find the article linked in the episode description and Consult Notes from CID entitled Fostering Collaborative Teamwork, A Comprehensive Approach to Vascular Graft Infection Following Arterial Reconstructive Surgery.
Sara Dong:Don't forget to check out the website, febrilepodcast.
Sara Dong:com, where you will find our consult notes, which are written complements to the episodes of links to references, our library of ID infographics, and a link to our merch store.
Sara Dong:Febrile is produced with support from the Infectious Diseases Society of America, IDSA.
Sara Dong:Editing and mixing was provided by Bentley Brown.
Sara Dong:Please reach out if you have any suggestions for future shows or want to be more involved with Febrile.
Sara Dong:Thanks for listening.
Sara Dong:Stay safe and I'll see you next time.
