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Differential Impact of Bypass Surgery and Angioplasty on Angiosome-Targeted Infrapopliteal Revascularization
Selected Abstracts from the April Issue of the European Journal of Vascular and Endovascular Surgery A. Ross Naylor, MBChB, MD, FRCS, Editor-in-Chief, and Philippe H. Kolh, MD, PhD, Senior Editor
Long-term Results of a Randomized Controlled Trial Analyzing the Role of Systematic Pre-operative Coronary Angiography before Elective Carotid Endarterectomy in Patients with Asymptomatic Coronary Artery Disease Illuminati G., Schneider F., Greco C., Mangieri E., Schiariti M., Tanzilli G., Barillà F., Paravati V., Pizzardi G., Calio’ F., Miraldi F., Macrina F., Totaro M., Greco E., Mazzesi G., Tritapepe L., Toscano M., Vietri F., Meyer N., Ricco J.-B. Eur J Vasc Endovasc Surg 2015;49:366-74. Objectives: To evaluate the potential benefit of systematic preoperative coronary-artery angiography followed by selective coronary-artery revascularization on the incidence of myocardial infarction (MI) in patients undergoing carotid endarterectomy (CEA) without a previous history of coronary artery disease (CAD). Methods: We randomised 426 patients who were candidates for CEA, with no history of CAD, a normal electrocardiogram (ECG), and a normal cardiac ultrasound. In group A (n ¼ 216) all patients underwent coronary angiography before CEA. In group B (n ¼ 210) CEA was performed without coronary angiography. Patients were not blinded for relevant assessments during follow-up. Primary end-point was the occurrence of MI at 3.5 years. The secondary end-point was the overall survival rate. Median length of follow-up was 6.2 years. Results: In group A, coronary angiography revealed significant coronary artery stenosis in 68 patients (31.5%). Among them, 66 underwent percutaneous Intervention (PCI) prior to CEA and 2 received combined CEA and coronary-artery bypass grafting (CABG). Postoperatively, no MI was observed in group A, whereas 6 MI occurred in group B, one of which was fatal (p ¼ .01). During the study period, 3 MI occurred in group A (1.4%) and 33 were observed in group B (15.7%), 6 of which were fatal. The Cox model demonstrated a reduced risk of MI for patients in group A receiving coronary angiography (HR,.078; 95% CI, 0.024-0.256; p < .001). In addition, patients with diabetes and patients <70 years presented with an increased risk of MI. Survival analysis at 6 years by Kaplan-Meier estimates was 95.6 6 3.2% in Group A and 89.7 6 3.7% in group B (Log Rank ¼ 6.54, p ¼ .01). Conclusions: In asymptomatic coronary-artery patients, systematic coronary angiography prior to CEA followed by selective PCI or CABG significantly reduces the incidence of late MI and increases long-term survival. (ClinicalTrials.gov number, NCT02260453). Angulation of the C-Arm During Complex Endovascular Aortic Procedures Increases Radiation Exposure to the Head Albayati M.A., Kelly S., Gallagher D., Dourado R., Patel A.S., Saha P., Bajwa A., El-Sayed T., Salter R., Gkoutzious P., Carrell T., Abisi S., Modarai B. Eur J Vasc Endovasc Surg 2015;49:396-402. Objectives/Background: The increased complexity of endovascular aortic repair necessitates longer procedural time and higher radiation exposure to the operator, particularly to exposed body parts. The aims were to measure directly exposure to radiation of the bodies and heads of the operating team during endovascular repair of thoracoabdominal aortic aneurysms (TAAA), and to identify factors that may increase exposure. Methods: This was a single-centre prospective study. Between October 2013 and July 2014, consecutive elective branched and fenestrated TAAA repairs performed in a hybrid operating room were studied. Electronic dosimeters were used to measure directly radiation exposure to the primary (PO) and assistant (AO) operator in three different areas (underlead, over-lead, and head). Fluoroscopy and digital subtraction angiography (DSA) acquisition times, C-arm angulation, and PO/AO height were recorded. Results: Seventeen cases were analysed (Crawford IIeIV), with a median operating time of 280 minutes (interquartile range 200e330 minutes). Median age was 76 years (range 71e81 years); median body mass index was
28 kg/m2 (25e32 kg/m2). Stent-grafts incorporated branches only, fenestrations only, or a mixture of branches and fenestrations. A total of 21 branches and 38 fenestrations were cannulated and stented. Head dose was significantly higher in the PO compared with the AO (median 54 mSv [range 24e130 mSv] vs. 15 mSv [range 7e43 mSv], respectively; p = .022), as was over-lead body dose (median 80 mSv [range 37e163 mSv] vs. 32 mSv [range 6e48 mSv], respectively; p = .003). Corresponding under-lead doses were similar between operators (median 4 mSv [range 1e17 mSv] vs. 1 mSv [range 1e3 mSv], respectively; p = .222). Primary operator height, DSA acquisition time in left anterior oblique (LAO) position, and degrees of LAO angulation were independent predictors of PO head dose (p < .05). Conclusions: The head is an unprotected area receiving a significant radiation dose during complex endovascular aortic repair. The deleterious effects of exposure to this area are not fully understood. Vascular interventionalists should be cognisant of head exposure increasing with C-arm angulation, and limit this manoeuvre. Short-term Outcome of Spinal Cord Ischemia after Endovascular Repair of Thoracoabdominal Aortic Aneurysms Dias N.V., Sonesson B., Kristmundsson T., Holm H., Resch T. Eur J Vasc Endovasc Surg 2015;49:403-9. Objective: To analyze the incidence and short-term outcome of SCI after endovascular repair of thoracoabdominal aneurysms (eTAAA). Methods: All patients undergoing eTAAA with branched and fenestrated stent grafts between 2008 and 2014 were retrospectively reviewed concerning pre-, intra- and post-operative clinical data and imaging. Results: Seventy-two patients (53 males, 68 [64e73] years old) underwent eTAAA (51 elective, 21 acute including 7 ruptures). Patients were classified anatomically according to Crawford: type I (n¼11), type II (n¼26), type III (n¼18), and type IV (n¼17). Thirty-day mortality was 6.9 % (3.9% for elective, 7.1% for symptomatic and 28.6% for ruptures, including one intra-operative death). Twenty-two of the 71 patients who survived the operation (31.0%) developed SCI: type I (n¼2, 20.0%), type II (n¼13, 50.0 %), type III (n¼3, 16.7%), type IV (n¼4, 23.5%). SCI incidence decreased in the latter part of the experience (23.7% vs. 39.4%, p ¼ .201). SCI development was independently associated with Crawford type II TAAA (OR 4.497 (1.331e15.195), p ¼ .016) and higher contrast volume (OR 3.736 [1.054e13.242], p ¼ .041). Fifteen of these 22 patients with SCI showed some improvement of their deficits before hospital discharge. The introduction of a standardized protocol in the last 38 patients aiming at the early diagnosis and treatment of SCI led to more frequent regression of SCI symptoms (100% vs. 46.2%, p ¼ .017) and a higher rate of regaining ambulatory capacity (55.6% vs. 15.4%, p ¼ .027). After the introduction of this protocol, the residual SCI rate at hospital discharge was 13.2% as opposed to 33.3% in the initial group. Conclusion: eTAAA has low peri-operative mortality, but SCI incidence is high albeit that it decreased with increasing experience. More extensive repair and use of larger volumes of contrast were associated with higher risk of SCI. Acute repair does not significantly increase SCI risk. A standardized protocol for early diagnosis and treatment of SCI leads to a higher recovery rate with a greater likelihood of regaining ambulatory capacity.
Differential Impact of Bypass Surgery and Angioplasty on Angiosome-Targeted Infrapopliteal Revascularization Spillerova K., Biancari F., Leppäniemi A., Albäck A., Söderström M., Venermo M. Eur J Vasc Endovasc Surg 2015;49:412-9. Objective: The aim of this study was to evaluate the impact of angiosome targeted revascularization according to the revascularization method.
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1102 Abstracts
Design: Retrospective observational study. Materials and methods: This study cohort comprised 744 consecutive patients who underwent infrapopliteal endovascular or surgical revascularization between January 2010 and July 2013. Differences in outcomes after bypass surgery and PTA were adjusted by estimating a propensity score, which was employed for one to one matching as well as adjusted analysis. Results: Cox proportional hazards analysis showed that angiosometargeted revascularization (HR 1.29, 95% CI 1.02e1.65), bypass surgery (HR 1.79, 95% CI 1.41e2.27), C-reactive protein #10 mg/dL (HR 1.42, 95% CI 1.11e1.81), and the number of affected angiosomes (HR 0.85, 95% CI 0.74e0.98) were independent predictors of improved wound healing. When adjusted for the number of affected angiosomes and C-reactive protein #10 mg/dL, angiosome-targeted bypass surgery was associated with a significantly higher rate of wound healing than non-angiosome-targeted angioplasty (HR 2.27, 95% CI 1.61e3.20). This was confirmed in propensity score adjusted analysis (HR 1.72, 95% CI 1.35e2.16). Among patients who underwent angiosome-targeted revascularization, the propensity score adjusted analysis showed that bypass surgery was associated with a significantly better rate of wound healing (HR 154, 95% CI 1.09e2.16) but similar limb salvage rates when compared with angioplasty (HR 0.79, 95% CI 0.44e1.43). Conclusion: Rates of wound healing and limb salvage in patients with critical limb ischemia (CLI) were significantly better after angiosome-targeted revascularization, bypass surgery achieving significantly better wound healing than angioplasty. Epidemiological Study on Chronic Venous Disease in Belgium and Luxembourg: Prevalence, Risk Factors, and Symptomatology Vuylsteke M.E., Thomis S., Guillaume G., Modliszewski M.L., Weides N., Staelens I. Eur J Vasc Endovasc Surg 2015;49:432-9. Objective: This epidemiological study measured the prevalence of chronic venous disease (CVD) in Belgium and Luxembourg. Possible risk factors and the symptomatology were evaluated. Material and methods: A survey was carried out in Belgium and Luxembourg between May and September 2013. Patient recruitment was carried out by 406 general practitioners (GPs). Each GP screened 10e20 consecutive patients older than 18 years, and in total 6009 patients were included. Patient characteristics, prevalence of risk factors, symptomatology, and C-classification were noted. The GPs diagnosed CVD and measured the need for treatment. Patients with diagnosed CVD completed a questionnaire about their history of leg problems and a quality of life score (CIVIQ-14). These data were converted into a CIVIQ Global Index Score (GIS). Results: The mean age of the patients was 53.4 years, and they were predominantly female (67.5%). Among the 3889 symptomatic patients, heavy legs, pain, and sensation of leg swelling were the most common complaints. Among the included patients, 61.3% of patients were classified
JOURNAL OF VASCULAR SURGERY April 2015
within C1-C6; however, only 45.9% of these patients were considered by the GPs to be suffering CVD. Treatment was offered to 49.5% of patients. Age and female gender correlate with a higher C-class (p < .001). Patients with a higher C-class (C3-C6) have significantly more pain, sensation of swelling and burning, night cramps, itching, and the sensation of “pins and needles” in the legs. Patients taking regular exercise and without a family history had a lower C-class. Higher BMI, age, female gender, family history, history of thrombophlebitis, and a higher C-class correlated with a lower GIS (p < .001). Of the patients with CVD, 10.4% had lost days of work because of their venous leg problems. Conclusion: CVD is a very common disease, which is underestimated. The prevalence increases with age, generates incapacity to work, and worsens the patients’ quality of life. Diagnostic Performance of 18F-FDG-PET/CT in Vascular Graft Infections Sah B.-R., Husmann L., Mayer D., Scherrer A., Rancic Z., Puippe G., Weber R., Hasse B., the Vasgra Cohort. Eur J Vasc Endovasc Surg 2015;49:455-64. Objective: The aim of this study was to evaluate the diagnostic accuracy of positron emission tomography/computed tomography with 18F-fludeoxyglucose (FDG-PET/CT) in a population with suspected graft infection and to validate a new diagnostic imaging score for FDG-PET/CT. Methods: This was a prospective cohort study. FDG-PET/CT was performed prospectively in 34 patients with suspected graft infection, in 12 of them before the start of antimicrobial treatment. Diagnostic accuracy was assessed using a new five point visual grading score and by using a binary score. Maximum standardized uptake values (SUVmax) were calculated for quantitative measurements of metabolic activity, and cut off points were calculated using the receiver operator curve (ROC). The standard of reference was a microbiological culture, obtained after open biopsy or graft explantation. Results: Using the new scale, FDG-PET/CT correctly recognized 27 patients with graft infection, one patient was diagnosed as false positive, six patients were correctly classified as true negative, and no patients were rated false negative. Hence, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of FDG-PET/CT for the diagnosis of graft infections were 100%, 86%, 96%, 100%, and 97%, respectively. Using a previously established binary score, sensitivity, specificity, PPV, NPV, and accuracy were 96%, 86%, 96%, 86%, and 94% respectively. ROC analysis suggested an SUVmax cut off value of $3.8 to differentiate between infected and non-infected grafts (p < .001). Additionally, FDGPET/CT provided a conclusive clinical diagnosis in six of seven patients without graft infection (i.e., other sites of infections). Conclusions: The diagnostic accuracy of FDG-PET/CT in the detection of aortic graft infection is high. A newly introduced five point visual grading score and early imaging prior to antimicrobial treatment may further improve the diagnostic accuracy.
Long-term Results of a Randomized Controlled Trial Analyzing the Role of Systematic Pre-operative Coronary Angiography before Elective Carotid Endarterectomy in Patients with Asymptomatic Coronary Artery Disease Illuminati G., Schneider F., Greco C., Mangieri E., Schiariti M., Tanzilli G., Barillà F., Paravati V., Pizzardi G., Calio’ F., Miraldi F., Macrina F., Totaro M., Greco E., Mazzesi G., Tritapepe L., Toscano M., Vietri F., Meyer N., Ricco J.-B. Eur J Vasc Endovasc Surg 2015;49:366-74. Objectives: To evaluate the potential benefit of systematic preoperative coronary-artery angiography followed by selective coronary-artery revascularization on the incidence of myocardial infarction (MI) in patients undergoing carotid endarterectomy (CEA) without a previous history of coronary artery disease (CAD). Methods: We randomised 426 patients who were candidates for CEA, with no history of CAD, a normal electrocardiogram (ECG), and a normal cardiac ultrasound. In group A (n ¼ 216) all patients underwent coronary angiography before CEA. In group B (n ¼ 210) CEA was performed without coronary angiography. Patients were not blinded for relevant assessments during follow-up. Primary end-point was the occurrence of MI at 3.5 years. The secondary end-point was the overall survival rate. Median length of follow-up was 6.2 years. Results: In group A, coronary angiography revealed significant coronary artery stenosis in 68 patients (31.5%). Among them, 66 underwent percutaneous Intervention (PCI) prior to CEA and 2 received combined CEA and coronary-artery bypass grafting (CABG). Postoperatively, no MI was observed in group A, whereas 6 MI occurred in group B, one of which was fatal (p ¼ .01). During the study period, 3 MI occurred in group A (1.4%) and 33 were observed in group B (15.7%), 6 of which were fatal. The Cox model demonstrated a reduced risk of MI for patients in group A receiving coronary angiography (HR,.078; 95% CI, 0.024-0.256; p < .001). In addition, patients with diabetes and patients <70 years presented with an increased risk of MI. Survival analysis at 6 years by Kaplan-Meier estimates was 95.6 6 3.2% in Group A and 89.7 6 3.7% in group B (Log Rank ¼ 6.54, p ¼ .01). Conclusions: In asymptomatic coronary-artery patients, systematic coronary angiography prior to CEA followed by selective PCI or CABG significantly reduces the incidence of late MI and increases long-term survival. (ClinicalTrials.gov number, NCT02260453). Angulation of the C-Arm During Complex Endovascular Aortic Procedures Increases Radiation Exposure to the Head Albayati M.A., Kelly S., Gallagher D., Dourado R., Patel A.S., Saha P., Bajwa A., El-Sayed T., Salter R., Gkoutzious P., Carrell T., Abisi S., Modarai B. Eur J Vasc Endovasc Surg 2015;49:396-402. Objectives/Background: The increased complexity of endovascular aortic repair necessitates longer procedural time and higher radiation exposure to the operator, particularly to exposed body parts. The aims were to measure directly exposure to radiation of the bodies and heads of the operating team during endovascular repair of thoracoabdominal aortic aneurysms (TAAA), and to identify factors that may increase exposure. Methods: This was a single-centre prospective study. Between October 2013 and July 2014, consecutive elective branched and fenestrated TAAA repairs performed in a hybrid operating room were studied. Electronic dosimeters were used to measure directly radiation exposure to the primary (PO) and assistant (AO) operator in three different areas (underlead, over-lead, and head). Fluoroscopy and digital subtraction angiography (DSA) acquisition times, C-arm angulation, and PO/AO height were recorded. Results: Seventeen cases were analysed (Crawford IIeIV), with a median operating time of 280 minutes (interquartile range 200e330 minutes). Median age was 76 years (range 71e81 years); median body mass index was
28 kg/m2 (25e32 kg/m2). Stent-grafts incorporated branches only, fenestrations only, or a mixture of branches and fenestrations. A total of 21 branches and 38 fenestrations were cannulated and stented. Head dose was significantly higher in the PO compared with the AO (median 54 mSv [range 24e130 mSv] vs. 15 mSv [range 7e43 mSv], respectively; p = .022), as was over-lead body dose (median 80 mSv [range 37e163 mSv] vs. 32 mSv [range 6e48 mSv], respectively; p = .003). Corresponding under-lead doses were similar between operators (median 4 mSv [range 1e17 mSv] vs. 1 mSv [range 1e3 mSv], respectively; p = .222). Primary operator height, DSA acquisition time in left anterior oblique (LAO) position, and degrees of LAO angulation were independent predictors of PO head dose (p < .05). Conclusions: The head is an unprotected area receiving a significant radiation dose during complex endovascular aortic repair. The deleterious effects of exposure to this area are not fully understood. Vascular interventionalists should be cognisant of head exposure increasing with C-arm angulation, and limit this manoeuvre. Short-term Outcome of Spinal Cord Ischemia after Endovascular Repair of Thoracoabdominal Aortic Aneurysms Dias N.V., Sonesson B., Kristmundsson T., Holm H., Resch T. Eur J Vasc Endovasc Surg 2015;49:403-9. Objective: To analyze the incidence and short-term outcome of SCI after endovascular repair of thoracoabdominal aneurysms (eTAAA). Methods: All patients undergoing eTAAA with branched and fenestrated stent grafts between 2008 and 2014 were retrospectively reviewed concerning pre-, intra- and post-operative clinical data and imaging. Results: Seventy-two patients (53 males, 68 [64e73] years old) underwent eTAAA (51 elective, 21 acute including 7 ruptures). Patients were classified anatomically according to Crawford: type I (n¼11), type II (n¼26), type III (n¼18), and type IV (n¼17). Thirty-day mortality was 6.9 % (3.9% for elective, 7.1% for symptomatic and 28.6% for ruptures, including one intra-operative death). Twenty-two of the 71 patients who survived the operation (31.0%) developed SCI: type I (n¼2, 20.0%), type II (n¼13, 50.0 %), type III (n¼3, 16.7%), type IV (n¼4, 23.5%). SCI incidence decreased in the latter part of the experience (23.7% vs. 39.4%, p ¼ .201). SCI development was independently associated with Crawford type II TAAA (OR 4.497 (1.331e15.195), p ¼ .016) and higher contrast volume (OR 3.736 [1.054e13.242], p ¼ .041). Fifteen of these 22 patients with SCI showed some improvement of their deficits before hospital discharge. The introduction of a standardized protocol in the last 38 patients aiming at the early diagnosis and treatment of SCI led to more frequent regression of SCI symptoms (100% vs. 46.2%, p ¼ .017) and a higher rate of regaining ambulatory capacity (55.6% vs. 15.4%, p ¼ .027). After the introduction of this protocol, the residual SCI rate at hospital discharge was 13.2% as opposed to 33.3% in the initial group. Conclusion: eTAAA has low peri-operative mortality, but SCI incidence is high albeit that it decreased with increasing experience. More extensive repair and use of larger volumes of contrast were associated with higher risk of SCI. Acute repair does not significantly increase SCI risk. A standardized protocol for early diagnosis and treatment of SCI leads to a higher recovery rate with a greater likelihood of regaining ambulatory capacity.
Differential Impact of Bypass Surgery and Angioplasty on Angiosome-Targeted Infrapopliteal Revascularization Spillerova K., Biancari F., Leppäniemi A., Albäck A., Söderström M., Venermo M. Eur J Vasc Endovasc Surg 2015;49:412-9. Objective: The aim of this study was to evaluate the impact of angiosome targeted revascularization according to the revascularization method.
1101
1102 Abstracts
Design: Retrospective observational study. Materials and methods: This study cohort comprised 744 consecutive patients who underwent infrapopliteal endovascular or surgical revascularization between January 2010 and July 2013. Differences in outcomes after bypass surgery and PTA were adjusted by estimating a propensity score, which was employed for one to one matching as well as adjusted analysis. Results: Cox proportional hazards analysis showed that angiosometargeted revascularization (HR 1.29, 95% CI 1.02e1.65), bypass surgery (HR 1.79, 95% CI 1.41e2.27), C-reactive protein #10 mg/dL (HR 1.42, 95% CI 1.11e1.81), and the number of affected angiosomes (HR 0.85, 95% CI 0.74e0.98) were independent predictors of improved wound healing. When adjusted for the number of affected angiosomes and C-reactive protein #10 mg/dL, angiosome-targeted bypass surgery was associated with a significantly higher rate of wound healing than non-angiosome-targeted angioplasty (HR 2.27, 95% CI 1.61e3.20). This was confirmed in propensity score adjusted analysis (HR 1.72, 95% CI 1.35e2.16). Among patients who underwent angiosome-targeted revascularization, the propensity score adjusted analysis showed that bypass surgery was associated with a significantly better rate of wound healing (HR 154, 95% CI 1.09e2.16) but similar limb salvage rates when compared with angioplasty (HR 0.79, 95% CI 0.44e1.43). Conclusion: Rates of wound healing and limb salvage in patients with critical limb ischemia (CLI) were significantly better after angiosome-targeted revascularization, bypass surgery achieving significantly better wound healing than angioplasty. Epidemiological Study on Chronic Venous Disease in Belgium and Luxembourg: Prevalence, Risk Factors, and Symptomatology Vuylsteke M.E., Thomis S., Guillaume G., Modliszewski M.L., Weides N., Staelens I. Eur J Vasc Endovasc Surg 2015;49:432-9. Objective: This epidemiological study measured the prevalence of chronic venous disease (CVD) in Belgium and Luxembourg. Possible risk factors and the symptomatology were evaluated. Material and methods: A survey was carried out in Belgium and Luxembourg between May and September 2013. Patient recruitment was carried out by 406 general practitioners (GPs). Each GP screened 10e20 consecutive patients older than 18 years, and in total 6009 patients were included. Patient characteristics, prevalence of risk factors, symptomatology, and C-classification were noted. The GPs diagnosed CVD and measured the need for treatment. Patients with diagnosed CVD completed a questionnaire about their history of leg problems and a quality of life score (CIVIQ-14). These data were converted into a CIVIQ Global Index Score (GIS). Results: The mean age of the patients was 53.4 years, and they were predominantly female (67.5%). Among the 3889 symptomatic patients, heavy legs, pain, and sensation of leg swelling were the most common complaints. Among the included patients, 61.3% of patients were classified
JOURNAL OF VASCULAR SURGERY April 2015
within C1-C6; however, only 45.9% of these patients were considered by the GPs to be suffering CVD. Treatment was offered to 49.5% of patients. Age and female gender correlate with a higher C-class (p < .001). Patients with a higher C-class (C3-C6) have significantly more pain, sensation of swelling and burning, night cramps, itching, and the sensation of “pins and needles” in the legs. Patients taking regular exercise and without a family history had a lower C-class. Higher BMI, age, female gender, family history, history of thrombophlebitis, and a higher C-class correlated with a lower GIS (p < .001). Of the patients with CVD, 10.4% had lost days of work because of their venous leg problems. Conclusion: CVD is a very common disease, which is underestimated. The prevalence increases with age, generates incapacity to work, and worsens the patients’ quality of life. Diagnostic Performance of 18F-FDG-PET/CT in Vascular Graft Infections Sah B.-R., Husmann L., Mayer D., Scherrer A., Rancic Z., Puippe G., Weber R., Hasse B., the Vasgra Cohort. Eur J Vasc Endovasc Surg 2015;49:455-64. Objective: The aim of this study was to evaluate the diagnostic accuracy of positron emission tomography/computed tomography with 18F-fludeoxyglucose (FDG-PET/CT) in a population with suspected graft infection and to validate a new diagnostic imaging score for FDG-PET/CT. Methods: This was a prospective cohort study. FDG-PET/CT was performed prospectively in 34 patients with suspected graft infection, in 12 of them before the start of antimicrobial treatment. Diagnostic accuracy was assessed using a new five point visual grading score and by using a binary score. Maximum standardized uptake values (SUVmax) were calculated for quantitative measurements of metabolic activity, and cut off points were calculated using the receiver operator curve (ROC). The standard of reference was a microbiological culture, obtained after open biopsy or graft explantation. Results: Using the new scale, FDG-PET/CT correctly recognized 27 patients with graft infection, one patient was diagnosed as false positive, six patients were correctly classified as true negative, and no patients were rated false negative. Hence, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of FDG-PET/CT for the diagnosis of graft infections were 100%, 86%, 96%, 100%, and 97%, respectively. Using a previously established binary score, sensitivity, specificity, PPV, NPV, and accuracy were 96%, 86%, 96%, 86%, and 94% respectively. ROC analysis suggested an SUVmax cut off value of $3.8 to differentiate between infected and non-infected grafts (p < .001). Additionally, FDGPET/CT provided a conclusive clinical diagnosis in six of seven patients without graft infection (i.e., other sites of infections). Conclusions: The diagnostic accuracy of FDG-PET/CT in the detection of aortic graft infection is high. A newly introduced five point visual grading score and early imaging prior to antimicrobial treatment may further improve the diagnostic accuracy.