March 18, 2020
ESVS 2020 Guidelines Published on the Management of Vascular and Endovascular Graft Infections
March 18, 2020—The European Society of Vascular Surgery (ESVS) recently announced that the 2020 clinical practice guidelines on the management of vascular and endovascular graft infections have been published by Nabil Chakfé, MD, et al in European Journal of Vascular and Endovascular Surgery (EJVES; 2020;59:339–384).
According to ESVS, the guidelines aim to assist physicians involved in the diagnosis and treatment of patients with vascular graft/endograft infections (VGEI) in selecting the best management strategy in different scenarios. The potential users of the guidelines include angiologists; vascular, cardiovascular and general surgeons; infectious disease physicians; and radiologists. The target population is composed of patients with VGEI in the supraaortic trunks, thoracic and/or abdominal aorta, and peripheral arteries. Sections of the guidelines specifically address each of these anatomies.
In the guidelines in EJVES, the writing committee cautioned that the literature review that was performed to propose the ESVS guidelines on VGEI demonstrated a lack of robust evidence in many aspects of VGEI management. The literature did not provide enough randomized controlled trials, but mostly retrospective studies, literature reviews, and some consensus articles. As a consequence, most recommendations in these guidelines have a low level of evidence, mostly level C.
As outlined in EJVES, even the conclusions of papers, including large series, are debatable for the following reasons: (1) Populations are difficult to compare because of the multiple clinical presentations, the different microbiology protocols for micro-organism sampling and studies, the different imaging modalities, and the different management options in terms of antimicrobial therapy duration, or choice of vascular substitutes. (2) Large series proposing treatment modalities have mostly been published by tertiary centers and most often favor one technique over another. Consequently, there is a high risk of bias related to only publishing positive results while probably not reporting poorer experiences. (3) Reviews and meta-analysis, potentially more valid than series, could help in establishing valuable comparisons between different management options. However, they still have to be interpreted with caution because of the previous comments on the potential heterogeneity of the series they pooled.
Consequently, the writing committee agreed on the necessity to set up large, multicenter registries that could include patients prospectively with predefined variables allowing for valuable comparisons and conclusions to answer unresolved issues on a variety of topics.