FDG-PET in Prosthetic Graft Infections

doi:10.1053/j.semnuclmed.2013.04.004

Seminars in Nuclear Medicine

Volume 43, Issue 5, September 2013, Pages 396-402

https://doi.org/10.1053/j.semnuclmed.2013.04.004 Get rights and content

Graft infection following prosthetic vascular reconstruction is an uncommon but severe complication. The clinical presentation is often subtle and nonspecific and may occur long after surgery. Although defining a prosthetic vascular graft infection can be difficult, early diagnosis and treatment are essential for the correct choice of treatment to prevent further complications as well as the high morbidity and mortality associated with repeat surgery and removal of infected grafts. False-positive results may lead to unnecessary surgery while failure to diagnose graft infection may have life-threatening sequels. Scarce literature that is currently available regarding the role of ¹⁸F-labeled fluorodeoxyglucose imaging for assessment of vascular graft infection suggests that this modality may represent reliable noninvasive imaging modality in this specific clinical setting. PET/CT increases the test specificity and thus improves diagnostic accuracy. The precise anatomic localization of increased ¹⁸F-labeled fluorodeoxyglucose PET/CT enables accurate differentiation between graft and adjacent soft tissue infection leading to more accurate diagnosis and subsequent optimized therapeutic strategy.

Section snippets

Vascular Graft Infection—Frequency, Pathogenesis, Clinical Symptomatology, and Diagnosis

Vascular graft infection is a severe complication following reconstructive surgery. Graft infection is rare, with an incidence ranging between 1% and 6%. Infection is caused either at the time of surgery, during procedures involving the inserted graft (such as revision or catheterization), or through involvement from an adjacent soft tissue focus. Late contamination in cases of bacteremia and sepsis has also been reported.³ The reasons for graft infection include patient-related,

The Role of FDG-PET/CT in the Assessment of Vascular Graft Infection

PET is a noninvasive metabolic imaging modality that provides tomographic data and quantitative parameters of perfusion, cell viability, proliferation, and metabolic tissue activity. FDG is at present the main PET radiopharmaceutical. FDG, a glucose analogue, is taken up by metabolically active cells via glucose transporters and phosphorylated to ¹⁸F-2′-FDG-6 phosphate, but not further metabolized. While being used as the major PET radiotracer in cancer imaging, FDG was also shown to accumulate

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Cited by (52)

FDG PET/CT in abdominal aortic graft infection: A case report and literature review
2023, Radiology Case Reports
Citation Excerpt :
Early signs of graft infection include abdominal pain, fever, chills, and malaise. Prolonged infection can present with signs of sepsis, fistulas, limb ischemia, and gastrointestinal hemorrhage [1,3,7,14]. Although there are no established gold-standard criteria for diagnosis of aortic graft infection (AGI), the Management of Aortic Graft Infection Collaboration (MAGIC) is a collective of clinicians who aim to construct a consistent diagnostic standard [15].
This case report follows a 47-year-old man who had multiple grafts undergoing FDG PET/CT (positron emission tomography/computed tomography) scan to evaluate for graft infection. Initial CT showed enhancing soft tissue and fluid collection around the graft, and the subsequent FDG PET/CT showed findings concerning for graft infection. This case exemplifies that FDG PET/CT is a synergistic tool in diagnosing aortic graft infections, a rare and often fatal complication of aortic grafts.
Diagnostic Accuracy of FDG PET for the Identification of Vascular Graft Infection
2022, Annals of Vascular Surgery
Citation Excerpt :
18F-FDG is mainly taken up by inflammatory cells and thus accumulates in areas of infection. When combined with CT, this modality provides a dual anatomic-pathophysiologic localization.14 Few studies have looked at the diagnostic utility of 18F-FDG PET/CT.
Fluorodeoxyglucose (FDG) positron emission tomography (FDG PET/CT) can be used to identify and localize infection in patients with vascular graft infections (VGI). We aimed to evaluate the diagnostic accuracy of 18F-FDG PET/CT by defining thresholds for standardized uptake value (SUV) and tissue-to-background ratio (TBR) that would accurately identify the presence of vascular graft infection.
Patients with suspected VGI were prospectively recruited and underwent 18F-FDG PET/CT scans. Diagnosis was based on clinical, laboratory and radiologic findings, and blinded to the results of the PET/CT scan. Receiver operator characteristics (ROC) curve analysis was done to determine optimal thresholds for SUV and TBR.
Our final cohort consisted of 28 patients with suspected VGI (mean ± SD age 67 ± 10 years, 61% men), of which 15 patients (54%) had definitive VGI. The cohort included 61% prosthetics grafts and 39% stent-grafts. The type of graft included in this study were biologic (4%), Dacron (64%) and Polytetrafluoroethylene (32%). The location of the implanted grafts was aortic (54%) and peripheral arterial reconstruction (46%). The location of the peripheral graft was 77% in lower extremity and 23% in the upper extremity (arterio-venous grafts for dialysis access). Using ROC analysis, SUV max of 4.5, SUV mean of 3.7, and a TBR of 1.6 gave the best balance between sensitivity and specificity (93%/92%, 100%/92% and 93%/92%, respectively). All thresholds had an area under the curve ≥0.93 and correct reclassification rate ≥93%.
Our data suggests that FDG PET/CT can be used to reliably and accurately diagnose VGI. The dual anatomic-physiologic information from FDG PET/CT can complement clinical diagnosis particularly in uncertain cases.
Limitations and Pitfalls of FDG-PET/CT in Infection and Inflammation
2021, Seminars in Nuclear Medicine
Citation Excerpt :
Of interest, some vascular grafts consist of materials that elicit a significant inflammatory response reflected by avid FDG uptake several years following the surgical procedure, most notably Dacron based prostheses.13 Implanted foreign materials can also be subject to sterile inflammation which may lead to elevated FDG uptake.14 This may be difficult to distinguish from low-grade infections.
White blood cells activated by either a pathogen or as part of a systemic inflammatory disease are characterized by high energy consumption and are therefore taking up the glucose analogue PET tracer FDG avidly. It is therefore not surprising that a steadily growing body of research and clinical reports now supports the use of FDG PET/CT to diagnose a wide range of patients with non-oncological diseases. However, using FDG PET/CT in patients with infectious or inflammatory diseases has some limitations and potential pitfalls that are not necessarily as pronounced in oncology FDG PET/CT. Some of these limitations are of a general nature and related to the laborious acquisition of PET images in patients that are often acutely ill, whereas others are more disease-specific and related to the particular metabolism in some of the organs most commonly affected by infections or inflammatory disease. Both inflammatory and infectious diseases are characterized by a more diffuse and less pathognomonic pattern of FDG uptake than oncology FDG PET/CT and the affected organs also typically have some physiological FDG uptake. In addition, patients referred to PET/CT with suspected infection or inflammation are rarely treatment naïve and may have received varying doses of antibiotics, corticosteroids or other immune-modulating drugs at the time of their examination. Combined, this results in a higher rate of false positive FDG findings and also in some cases a lower sensitivity to detect active disease. In this review, we therefore discuss the limitations and pitfalls of FDG PET/CT to diagnose infections and inflammation taking these issues into consideration. Our review encompasses the most commonly encountered inflammatory and infectious diseases in head and neck, in the cardiovascular system, in the abdominal organs and in the musculoskeletal system. Finally, new developments in the field of PET/CT that may help overcome some of these limitations are briefly highlighted.
PET/CT with 18F-Fluordesoxyglucose in patients with suspected endovascular prosthesis infection
2021, Revista Espanola de Medicina Nuclear e Imagen Molecular
La infección de prótesis vasculares de grandes vasos es una complicación poco frecuente pero crítica. El objetivo de este trabajo es valorar el impacto del PET/TC con ¹⁸F-Fluordesoxiglucosa (PET-FDG) en el diagnóstico de infección en nuestro entorno.
Se evaluaron 35 pacientes (38 exploraciones) por sospecha de infección protésica. Se realizó un análisis cualitativo teniendo en cuenta la distribución del radiofármaco, categorizando los estudios como positivos o negativos para infección. Se consideraron positivos aquellos que presentaban depósitos focales o multifocales a lo largo de la prótesis vascular, y negativos si se observaba una distribución homogénea y difusa sobre la totalidad de la prótesis, o la ausencia total de captación. Se realizó un análisis semicuantitativo empleando los valores SUVmax y SUVmedio, y se calculó un índice metabólico (SUVmax del injerto/SUVmedio del pool vascular normal).
El estudio PET-FDG fue positivo en 20 pacientes, con una precisión diagnóstica del 84%. Las 38 exploraciones PET-FDG realizadas mostraron patrones de captación positivos (focal en 6, multifocal en 15, difuso en 4) y patrón negativo en los 13 restantes. Los valores de sensibilidad, especificidad, valor predictivo positivo y negativo obtenidos para el PET-FDG fueron del 95%, 89%, 90% y 94%, y para el estudio AngioTC del 50%, 73%, 73% y 50%, respectivamente. Los valores del área bajo la curva ROC fueron los siguientes: para el AngioTC 0,642 (no significativo), y para los valores del SUVmax de 0,925 (p < 0,005), SUVmedio de 0,922 (p < 0,005) y para el índice metabólico de 0,917 (p < 0,005).
El PET-FDG demuestra ser una herramienta con una elevada precisión diagnóstica en la infección de prótesis vasculares, tanto el análisis visual según patrones como el semicuantitativo.
Infection of large vessel prostheses is a rare but critical complication. The aim of this work is to assess the impact of PET/CT with 18F-Fluordesoxyglucose (PET-FDG) on the diagnosis of infection in our environment.
Thirty-five patients (38 scans) were evaluated for suspected prosthetic infection. A qualitative analysis was performed taking into account the distribution of the radiopharmaceutical, categorizing the studies as positive or negative for infection. Those with focal or multifocal deposits along the vascular prosthesis were considered positive, and negative if a homogeneous and diffuse distribution over the whole prosthesis was observed, or a total absence of uptake. A semi-quantitative analysis was performed using SUVmax and average SUV values, and a metabolic index was calculated (SUVmax of the graft / average SUV of the normal vascular pool).
The PET-FDG study was positive in 20 patients, with a diagnostic accuracy of 84%. The 38 PET-FDG scans performed showed positive capture patterns (focal in 6, multifocal in 15, diffuse in 4) and negative pattern in the remaining 13. The sensitivity, specificity, positive and negative predictive values obtained for the PET-FDG were 95%, 89%, 90% and 94%, and for the AngioTC study 50%, 73%, 73% and 50%, respectively. The area values under the ROC curve were as follows: for the AngioTC 0.642 (not significant), and for the SUVmax values of 0.925 (p < 0.005), average SUV of 0.922 (p < 0.005) and for the metabolic index of 0.917 (p < 0.005).
The PET-FDG proves to be a tool with high diagnostic accuracy in the infection of vascular prosthesis, both visual analysis according to patterns and semi-quantitative.
A systematic review and meta-analysis of <sup>18</sup>F-fluorodeoxyglucose positron emission tomography or positron emission tomography/computed tomography for detection of infected prosthetic vascular grafts
2019, Journal of Vascular Surgery
The purpose of this investigation was to evaluate the diagnostic accuracy of ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET) or PET/computed tomography (PET/CT) for the detection of vascular prosthetic graft infection (VPGI) using a diagnostic accuracy test.
The MEDLINE/PubMed and Embase databases, from the earliest available date of indexing through March 31, 2018, were searched for results investigating the diagnostic accuracy of ¹⁸F-FDG PET or PET/CT for the detection of VPGI. We calculated the pooled sensitivities and specificities of included studies, calculated positive and negative likelihood ratios, and obtained summary receiver operating characteristic curves.
Across 10 studies (286 patients), the pooled sensitivity was 0.96 (95% confidence interval [CI], 0.89-0.98) without heterogeneity (I² = 40.2; 95% CI, 0.0-84.4; P = .09), and pooled specificity was 0.74 (95% CI, 0.67-0.81) without heterogeneity (I² = 39.9; 95% CI, 0.0-84.3; P = .09). Likelihood ratio syntheses showed an overall positive likelihood ratio of 3.7 (95% CI, 2.9-4.9) and negative likelihood ratio of 0.06 (95% CI, 0.02-0.15). The pooled diagnostic odds ratio was 63 (95% CI, 23-173). The hierarchical summary receiver operating characteristic curve showed the area under the curve to be 0.87 (95% CI, 0.83-0.89).
This study showed the high sensitivity and moderate specificity of ¹⁸F-FDG PET or PET/CT for the detection of VPGI. The clinical usefulness of ¹⁸F-FDG PET or PET/CT for detection of VPGI should be validated through further large multicenter studies.
18F-FDG PET in the Diagnosis of Vascular Prosthetic Graft Infection: A Diagnostic Test Accuracy Meta-Analysis
2019, European Journal of Vascular and Endovascular Surgery
For the diagnosis of vascular prosthetic graft infection (VPGI), an intra-operative peri-graft biopsy is often required. Controversy exists regarding the use of imaging techniques in the diagnostic process. This study aimed to evaluate the diagnostic accuracy of 18-fluorine fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) in VPGI.
A systematic search of electronic databases was conducted, applying a combination of free text and controlled vocabulary searches adapted to thesaurus headings, search operators, and limits to identify studies assessing the use of 18F-FDG PET in the diagnosis of VPGI. A meta-analysis was conducted using a mixed effects logistic regression bivariate model.
Twelve studies were identified reporting a total of 433 prostheses, of which 202 were proven to be infected. Analysis of PET scan was performed using five different methods: graded uptake, focal uptake, maximum standardised uptake value (SUVmax), tissue to background ratio (TBR), and dual time point (DTP). The pooled estimates for sensitivity and specificity for graded uptake were 0.89 (95% CI 0.73–0.96) and 0.61 (95% CI 0.48–0.74), respectively; they were 0.93 (95% CI 0.83–0.97) and 0.78 (95% CI 0.53–0.92) for focal uptake; 0.98 (95% CI 0.42–0.99) and 0.80 (95% CI 0.70–0.88) for SUVmax; 0.57 (95% CI 0.39–0.73) and 0.76 (95% CI 0.64–0.85) for TBR; and 1.00 (95% CI 0.48–1.00) and 0.88 (95% CI 0.68–0.97) for DTP. Sensitivity analysis including studies that investigated the diagnostic accuracy of PET combined with computed tomography (CT) showed higher sensitivity and specificity for focal uptake, graded uptake, and SUVmax than 18F-FDG PET alone.
This meta-analysis suggests that 18F-FDG PET has a high sensitivity in diagnosing VPGI and its accuracy can be further increased by combining PET with CT.

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FDG-PET in Prosthetic Graft Infections

Section snippets

Vascular Graft Infection—Frequency, Pathogenesis, Clinical Symptomatology, and Diagnosis

The Role of FDG-PET/CT in the Assessment of Vascular Graft Infection

Am J Surg

J Vasc Surg

J Infect

J Vasc Surg

Surg Clin North Am

Am J Surg

J Vasc Surg

J Vasc Surg

Ann Vasc Surg

Semin Nucl Med

Semin Vasc Surg

Eur J Vasc Endovasc Surg

J Vasc Surg

J Vasc Surg

Mol Imaging Biol

J Vasc Surg

Eur J Vasc Endovasc Surg

J Nucl Cardiol

Semin Nucl Med

Management of patients with prosthetic vascular graft infection

Am Surg

Graft-related complications after abdominal aortic aneurysm repair: Reassurance from a 36-year population-based experience

J Vasc Surg

Vascular graft infections

Swiss Med Wkly

Are gram-negative bacteria a contraindication to selective preservation of infected prosthetic arterial grafts?

J Vasc Surg