Die europäischen Leitlinien zur Versorgung von Gefäßprothesen- und Stentgraftinfektionen

Kommentierte Zusammenfassung

The European guidelines on treatment of vascular graft and endograft infections

Summary with comments

Zusammenfassung

Protheseninfektionen treten mit einer Häufigkeit von 0,5–6 % in Abhängigkeit von der Art des Eingriffs, der Lokalisation und des Stadiums einer begleitenden arteriellen Verschlusskrankheit (AVK) auf. Für Eingriffe an den unteren Extremitäten und der Leiste besteht ein höheres Infektionsrisiko (bis 6 %) als für Operationen im aortalen Segment (bis 3,6 %). Die MAGIC-Kriterien der Management of Aortic Graft Infection Group, bestehend aus klinischen, radiologischen und laborchemischen Untersuchungen zur Sicherung der Diagnose, werden empfohlen. Bildgebend sollte neben einer Ultraschalluntersuchung eine Computertomographie-Angiographie (CTA) erfolgen. Additiv kann ein 18-F-FDG-PET/CT („18F-fluoro-D-deoxyglucose positron emission tomography/computed tomography“) zur Bestätigung der Diagnose sinnvoll sein. Mikrobiologisch ist der Nachweis durch drei direkt gewonnene Proben anzustreben.

Therapie der ersten Wahl sind die vollständige Explantation sowie In-situ-Rekonstruktion mit autologem Material. Ein Bridging durch Stentgrafts bei akuten Blutungen kann im Einzelfall gerechtfertigt sein. Das Vorhandensein von aortobronchialen, -pulmonalen oder -enteralen Fisteln verschlechtert die Gesamtprognose signifikant. Eine zusätzliche Sanierung der fisteltragenden Begleitorgane ist empfehlenswert. Eine konservative Vorgehensweise gilt als palliatives Konzept bei nicht operationsfähigen Patienten. In diesen Fällen sollen additive Maßnahmen wie eine gezielte Drainagenanlage, Irrigation und Stentgraftimplantation zur Überbrückung lebensbedrohlicher Komplikationen angewandt werden. Dauer und Art der Antibiotikatherapie sind individuell und interdisziplinär unter Einbeziehung von Infektiologen festzulegen. Eine lebenslange Überwachung der Patienten nach Rekonstruktion wird empfohlen.

Abstract

Prosthesis infections occur with a frequency of 0.5–6% depending on the type of intervention, localization and stage of an accompanying arterial occlusive disease (AOD). There is a higher risk of infection (up to 6%) for operations on the lower extremities and the groin than for operations in the aortic segment (up to 3.6%). The management of aortic graft infection collaboration (MAGIC) criteria, consisting of clinical, radiological and laboratory investigations, are recommended for clinical confirmation of the diagnosis. In addition to an ultrasound examination, computed tomography (CT) angiography is recommended. In the case of insufficient information an 18F-fluorodesoxyglucose positron emission tomography CT (18-F-FDG PET/CT) can be useful. Microbiological detection should be attempted using three directly obtained samples.

The treatment of first choice is a complete explantation and in situ reconstruction with autologous material. Bridging by stent grafts for acute hemorrhage should be considered in each individual case. The presence of aortobronchial, aortopulmonary and aortoenteric fistulas worsens the prognosis. An additional reconstruction of the fistula-bearing sections of the affected accompanying organs is recommended. A conservative approach can be considered as a palliative concept in patients who are unfit for surgery. In these cases additive measures, such as targeted drainage placement, irrigation and stent graft implantation should be individually applied to bridge life-threatening complications. The duration and type of antibiotic treatment must be determined individually and in interdisciplinary collaboration by including infectious disease specialists. Lifelong surveillance of patients after reconstruction is recommended.

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Correspondence to Dr. H. Diener.

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H. Diener, N. Chakfe und S. Honig geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Der Aufbau dieses Beitrags ist hinsichtlich der Überschriftennummerierung an die englische Originalversion [1] angelehnt.

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Diener, H., Chakfe, N. & Honig, S. Die europäischen Leitlinien zur Versorgung von Gefäßprothesen- und Stentgraftinfektionen. Gefässchirurgie 25, 632–642 (2020). https://doi.org/10.1007/s00772-020-00712-6

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Schlüsselwörter

  • Vaskuläre Infektionen
  • Aorta
  • Thorakoabdominell
  • Extremitäten
  • In-situ-Rekonstruktion

Keywords

  • Vascular infections
  • Aorta
  • Thoracoabdominal
  • Extremities
  • In situ reconstruction