1. Early and late onset vascular graft infections – Surgical dilemmas Pranav Somaiya Developmental Lead, Proteomics,NPIMR(affl. UCL) SpR, Vascular Surgery, Queens Hospital, Romford

2. Talk content Definitions Diagnosis Treatment options The course ahead…..

3. Definitions difficult however there are well developed systems of classification of prosthetic vascular graft infections (PVGIs) for the purposes of today’s talk I will be focusing on Samson Groups 3-5

4. Diagnosis – Existing tools Microbiology based techniques: - culture - PCR and sonication techniques Imaging techniques - CT scans - PET scans

5. CT scans

7. Diagnosis - Microbiology Standard microbiology based techniques are woefully inadequate No standards are set nationally on methods for microbiology based diagnostics for clinical laboratories to follow No guidelines are agreed on tissue handling of PVGI explants

8. Treatment – Medical Management non-surgical treatment is reserved for patients who are surgically deemed unfit for surgery due to associated co-morbidities the standard treatment is long term oral antibiotic administration

9. Treatment – Surgical Management To explant or not to explant is the question? P Somaiya – circa 2012

10. Treatment – Surgical Management Samson group 3 PVGIs respond best to graft salvage and muscle flaps for tissue cover (Zetrenne et al, 2006) with better limb salvage rates and lower mortality microbiology plays a major role in the salvage of these grafts and certain organisms like MRSA are thought to be associated with higher limb loss

11. Treatment – Surgical Management Data on explanting of Samson group 4 and 5 is patchy and there is clear management strategy for patients, although explantation of the graft is carried out in a majority of the situations microbiology plays a relatively minor role in management of these patients

12. Treatment – Surgical Management How now? Anatomic or extra anatomic? Dead… P Somaiya – circa 2012

13. Treatment – Surgical Management Extra – Anatomic By pass after explanting of original graft

14. Treatment – Surgical Management Anatomic By pass after explanting of original graft

15. the course ahead…..

16. Thanks Vascular Surgery Unit, Directorate of General Surgery, Queen’s Hospital, Romford Prof. Homer-Vanniasinkam, LGI, Leeds Prof. Valerie Edwards-Jones, MMU, Manchester Our Research Team, Centre for Investigational Proteomics, NPIMR( affl. UCL)