TRATTAMENTO DELLE INFEZIONI NELL’EVAR · Elio Piccinini U.O.C. Chirurgia Vascolare ed...

Elio PiccininiU.O.C. Chirurgia Vascolare ed Endovascolare Ravenna

AUSL Romagna

SIMPOSIO EVAR – RER

TRATTAMENTO DELLE INFEZIONI NELL’EVAR

“ Quando colui che ascolta non capisce colui che parla , e colui che parla non sa cosa sta dicendo :

questa è filosofia “.

#2 . AAA #3 .INFEZIONE

1. EVAR

2. AAA :

• INFETTO

1885 W. Osler

2014-16-17 K Sorelius

• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO

2003 Marques da Silva

2007 Human Microbiome

2015 Vascular Microbiome

2016 Capnocytophaga canimorsus

3. INFEZIONE

1974 Finseth-Abbott

2013 Wolf in Shepp’s Clothing

4. RER

2017 SICHER

2017 AUSL.Romagna

5. TRATTAMENTO DELLE

INFEZIONI NELL ’ EVAR

#1 . EVAR #4 . RER / AUSL


“ Quando colui che ascolta non

capisce colui che parla , e colui

che parla non sa cosa sta dicendo

:

questa è filosofia “.

1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna



#1 . EVAR


ARGYRIOU 2017 0.6%

MAEFISTO 2016 3.9 %

“ Remote Endoprosthetic Repair ”( R.E.R.)

Volodos 1985

T.EVAR , F.EVAR , B.EVAR , ch.EVAR , R.EVAR , P.EVAR , EVA.S , ch.EVAS …

1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna



#1 . EVAR


1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna




INFETTO

• 1885 W. Osler

• 2014 – 2016 - 2017 K Sorelius

#2 . AAA

SOSPETTO

• 2016 M.A.G..IC.

• 2016 M.A.E.F.I.S.T.O.

NON INFETTO

• 2003 Marques da Silva

• 2007 Human Microbiome

• 2015 Vascular Microbiome

• 2016 Capnocytophaga canimorsus

#2 . AAA

“… it may be presumed that ….the larger sac presented a condition of mycotic

endarteritis unique in my experience of aortic aneurysms.”

1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna




THE GULSTONIAN LECTURES

ON

ENDOCARDITIS

Delivered at the Royal College of Physicians of London , march ,

1885

By WILLIAM OSLER M.D.

1. Osler W. Malignant endocarditis: lecture I. Lancet. March 7

,1885;1:467– 470.

2. Osler W. Malignant endocarditis: lecture II. Lancet. March 14

,1885;1:522 –526

3. Osler W. Malignant endocarditis: lecture III. Lancet. March 21

,1885;1:577 –579

1. Sörelius K, Mani K, Björck M, Sedivy P, Wahlgren CM, Taylor P, Clough RE, Lyons O,

Thompson M, Brownrigg J, Ivancev K, Davis M, Jenkins MP, Jaffer U, Bown M, Rancic Z,

Mayer D, Brunkwall J, Gawenda M, Kölbel T, Jean-Baptiste E, Moll F, Berger P, Liapis CD,

Moulakakis KG, Langenskiöld M, Roos H, Larzon T, Pirouzram A , Wanhainen A;

European MAA collaborators. Endovascular treatment of mycotic aortic aneurysms:

a European multicenter study.

Circulation. 2014 Dec 9;130(24):2136-42.

2. Sörelius K, Wanhainen A, Furebring M, Björck M, Gillgren P, Mani K; Swedish Collaborator Group for Mycotic Abdominal

Aortic Aneurysms*.

Nationwide Study of the Treatment of Mycotic Abdominal Aortic Aneurysms Comparing Open and Endovascular

Repair.

Circulation. 2016 Dec 6;134(23):1822-1832.

3. Sörelius K, Mani K, Björck M, Wanhainen A.

Endovascular treatment of mycotic aortic aneurysms: a paradigm shift.

J Cardiovasc Surg (Torino). 2017 Dec;58(6):870-874.

Conclusion

Endovascular treatment of MAA is feasible and for most patients a durable treatment option. Late infection–

related complications do occur, are often lethal, and warrant longterm antibiotic treatment and follow-up,

especially in patient with non-Salmonella–positive blood culture. In those cases, EVAR could be

considered a palliative option or a bridge to later elective open repair.

Conclusion

Although the role of EVAR for MAAA has been questioned because of the perceived risk of reinfection, the

present study indicates that EVAR for MAAA is associated with better short-term survival in comparison with

OR, and comparable long-term results in terms of survival and infectionrelated complications or reinterventions.

In Sweden, EVAR has been the primary surgical technique used for MAAAs in recent years, and data suggest

that more patients are being offered treatment after the introduction of EVAR.

On the basis of the results of the present cohort study, it seems justified to regard EVAR as an

acceptable alternativeto traditional OR for the treatment of MAAAs.

1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna



1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna



“ There is no universally accepted aortic graft infection case definition”

1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna



2016

1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna



2016

Aortic graft infection (AGI) is :

•suspected in a patient with

any isolated major criterion,

or

minor criteria from two of the three categories

•diagnosed in the presence of

a single major criterion,

plus

any other criterion (major or minor) from another category.

1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna



2016

Aortic graft infection (AGI) is :

•suspected in a patient with

any isolated major criterion,

or

minor criteria from two of the three

categories

•diagnosed in the presence of

a single major criterion,

plus

any other criterion (major or minor)

from another category.

1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna



1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna



“ Thus it may be concluded that aortic aneurysms contain bacteria.

However, the presence of bacteria in aortic aneurysms does not necessarily imply a causal

relationship, and some organisms may actually be secondary colonizers after aneurysm formation.

In any case, it is unlikely that viable and multiplying organisms detected inside the aneurysm wall

tissue are harmless “.

1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna



1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna



Curr Opin Rheumatol 2015, 27 : 397 - 405

1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna



2017

1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna



MRSA

MDRO

BACTERIA PHYLUM CLASSE ORDINE FAMIGLIA GENERE SPECIE

ENTEROBACTERIALES -ENTEROBACTERIACEAE

KLEBSIELLA - K. PNEUMONIAE

ESCHERICHIA - E. COLI

MORAXELLACEAE - ACINETOBACTER - A. BAUMANII

PSEUDOMONADACEAE - PSEUDOMONAS- P. AERUGINOSA

PSEUDOMONADALES

CPE

BACTERIA - PROTEOBACTERIA - GAMMAPROTEOBACTERIA

1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO




3. INFEZIONE

1974 Finseth-Abbott

2016 Human Microbiome Map

4. RER

2017 SICHER

2017 AUSL.Romagna



MRSA

MDRO

CPE

1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna



1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna



ANN VASC SURG 2016

#3 .INFEZIONE

1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna




A WOLF IN SHEEP’S CLOTHING

#3 .INFEZIONE

1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna



1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna



#4 . RER / AUSL


2016 LINEE GUIDA RER PER FLUSSO SICHER

CATEGORIE DI INTERVENTO E RELATIVI CODICI ICD9-CN

1.AAA Riparazione di aneurisma aortico 38.34,38.44,38.64

2. Durata della sorveglianza : 90 giorni se e’ stato utilizzato

materiale protesico

1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna




#4 . RER / AUSL

MRSA CPE

1. EVAR

2. AAA :

• INFETTO

1885 W. Osler


• SOSPETTO

2016 M.A.G..IC.

2016 M.A.E.F.I.S.T.O.

• NON INFETTO





3. INFEZIONE

1974 Finseth-Abbott


4. RER

2017 SICHER

2017 AUSL.Romagna




#4 . RER / AUSL

DOMANDE:

1. INCIDENZA ?

2. REGOLE ?

2016 AHA SCIENTIFIC STATEMENT

3. EVIDENZE ?

2017 ARGYRIOU

SYSTEMATIC REVIEW

/META-ANALYSIS

4. ALGORITMI OPERATIVI ?

2016 SMEDS

VASCULAR LOW-FREQUENCY

DISEASE CONSORTIUM

ARGYRIOU 2017 0.6% vs MAEFISTO 2016 3.9 %

2016

DOMANDE:

1. INCIDENZA ?

2. REGOLE ?


3. EVIDENZE ?

2017 ARGYRIOU

SYSTEMATIC REVIEW

/META-ANALYSIS


2016 SMEDS


DISEASE CONSORTIUM

2016

Algorithm for intraabdominal

vascular graft infection

management

DOMANDE:

1. INCIDENZA ?

2. REGOLE ?


3. EVIDENZE ?

2017 ARGYRIOU

SYSTEMATIC REVIEW

/META-ANALYSIS


2016 SMEDS


DISEASE CONSORTIUM

DOMANDE:

1. INCIDENZA ?

2. REGOLE ?


3. EVIDENZE ?

2017 ARGYRIOU

SYSTEMATIC REVIEW

/META-ANALYSIS


2016 SMEDS


DISEASE CONSORTIUM

DOMANDE:

1. INCIDENZA ?

2. REGOLE ?


3. EVIDENZE ?

2017 ARGYRIOU

SYSTEMATIC REVIEW

/META-ANALYSIS


2016 SMEDS


DISEASE CONSORTIUM

NOT

REPORTED

59

NO

TREATMENT

1

CONSERVATIVE

TREATMENT

9

IN SITU

RECONSTRUCTION

233

ENDOVASCULAR

TREATMENT

2

PATIENTS

362

EXTRA-ANATOMICAL

BYPASS

58

DOMANDE:

1. INCIDENZA ?

2. REGOLE ?


3. EVIDENZE ?

2017 ARGYRIOU

SYSTEMATIC REVIEW

/META-ANALYSIS


2016 SMEDS


DISEASE CONSORTIUM

DOMANDE:

1. INCIDENZA ?

2. REGOLE ?


3. EVIDENZE ?

2017 ARGYRIOU

SYSTEMATIC REVIEW

/META-ANALYSIS


2016 SMEDS


DISEASE CONSORTIUM

Fatima J, Duncan AA, de

Grandis E, Oderich GS,

Kalra M, Gloviczki P, et al.

Treatment strategies and

outcomes in patients with

infected aortic endografts.

J Vasc Surg2013;58:371-9.

DOMANDE:

1. INCIDENZA ?

2. REGOLE ?


3. EVIDENZE ?

2017 ARGYRIOU

SYSTEMATIC REVIEW

/META-ANALYSIS


2016 SMEDS


DISEASE CONSORTIUM

GRAZIE

TRATTAMENTO DELLE INFEZIONI NELL’EVAR · Elio Piccinini U.O.C. Chirurgia Vascolare ed...

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