110: StAR: Vascular Graft Infections

First up, we have Dr. Hussam Tabaja, who is an assistant professor of medicine in the Division of ID. He completed his internal medicine residency at the Detroit Medical Center and Wayne State University. Following that, he moved to Rochester, where he completed his three year ID fellowship at Mayo Clinic. His clinical research is focused on hardware associated infections, including both cardiovascular device and orthopedic device infections.

His clinical and research interests focus on the prevention, diagnosis, and management of infective endocarditis, cardiac implantable electronic device infections, and vascular graft infections.

That's kind of been something I've done over the last, not so much in the winter here because it gets quite cold in Rochester, but definitely in the spring, summer, late fall, and fall I've gotten into trying smoking on my grill and you got these little smoker tubes and you can get different pellets and it's just like a whole nother subculture that like, I just got into it's dangerous. It's a rabbit hole, but it's fun. And, uh, I'm Italian.

So we enjoy, we enjoy eating and we enjoy watching people eat. That's just my Italian call. That's what my Nana used to do is she would just make food and watch us eat. So I have that same passion.

And so I thought I'd actually start by opening up to give you an opportunity to just introduce the topic and actually the terminology because I think that sometimes the use of graft infection can be a bit broad and interpreted differently by various people. So yeah, would you guys introduce us to the topic?

So, to the first point, if I will give you a simple definition, it'll be an infection of a vascular graft used for vascular reconstruction. But of course, like you said, vascular reconstruction is a very broad terminology, so we need to be a bit more specific.

In this review, what we are focusing on is an infection of any graft material, whether biologic or synthetic, that is used to repair arterial aneurysms or pseudoaneurysms through either an endovascular approach or an open surgical approach that involves arteries both intracavitary and extracavitary. In that definition, what I did is I actually defined five different aspects that I think are very important to help specify the patient.

So we are saying that this review will focus and will be relative to both graft material types, which broadly there are two different graft materials. There is a biologic and synthetic. We are saying that this is going to be specifically about arteries, not veins. The pathology will be specifically aneurysms and pseudoaneurysms. This does not relate to hemodialysis graft, for example. We are saying that this document is relative to both surgical techniques.

There are two different surgical techniques for vascular reconstruction, so both endovascular and open surgical, and this review will apply to that, and the last point is that we're covering both the intracavitary and the extracavitary arteries. And I think it's also important to clarify this further. So intracavitary means that the artery is inside a cavity, like an abdomen or a chest, and extracavitary means that the artery is outside. So it could be in the groin, in the thigh, in the leg.

For this review specifically, we are including the entire arterial tree and arterial system, but we are excluding ascending aortas because ascending aortas are unique. They have different ways to diagnose and to manage, and so they do not fit in this review. This review is talking about the rest of the arterial system. So that's to point number one. Uh, point number two is what are we trying to achieve in this review?

What we want to do is we want to describe a model of care that we think institutions can apply in order to ensure effective prevention, diagnosis, and management of vascular graft infection. And we are hoping to do that through the clinical vignettes that we're going to be discussing in this podcast. The central theme for this model of care is the multidisciplinary collaboration.

If you look at the graphic abstract, we actually have a picture of a vascular graft infection and there is a ring around it. And on the ring, there are some bubbles or circles, and within those circles, we have listed different healthcare personnel or hospital teams that we think have an essential role in providing high quality care for the patient. So this is a very important collaborative network in order to be able to actually care for those patients. We need a lot of resources.

This is a very complex condition. If you look at those circles, there are three that are highlighted with dark blue compared to the others which are light blue. So these three are the patient, the vascular surgeon, and the infectious disease provider.

What we are trying to say here is that this collaborative network is put together, guided, and directed by those three, but it is a team effort, and so if any other members are missing, neither the vascular surgeon nor the infectious disease doctor will be able to provide high quality care for the patient.

This is a very important point in this paper, and it brings me to one point that we actually make at the very end, which is for a center to be able to provide this good or high quality care for the patient, they have to have minimum capabilities. If they don't, then it's very important that this patient be transferred to a center that has all of these substantial and very important resources for providing high quality care for this patient.

So this will be kind of an overview of what we're trying to do here in this paper.

The patient is a tobacco smoker and has a history of diabetes, hypertension, and stage 2 CKD. He reports a childhood allergy to penicillin. In this pre op setting, what evaluations do we need to think about to help mitigate both his risk of surgical site infection and or vascular graft infection?

Some other things to consider, again, not this patient, but in addition to what this patient has, malnutrition. So the patient's nutritional status, it's something that often is overlooked, but it's an elective procedure. If we have time to improve this patient's nutrition, if, if they were malnourished, that's very helpful from a healing standpoint, right? So they have to go through the surgery, survive the surgery, but then have to recover.

And it's during that recovery phase where that wound that does not close or where just the substrate, this patient's substrate just doesn't have the ability to close. Well, now you have that open wound, depending on how it was repaired, that's now a potential portal of entry for organisms. So that's something that I feel is often overlooked. And again, in addition to diabetes, chronic renal disease, if there's underlying malignancy, and peripheral arterial disease.

So these are some of your major risk factors related to the patient. Then you also have to factor in just the perioperative risk factors as well. And if you take a look at figure four in our document, you'll see we have this all kind of laid out nicely pre op, intra op, and post op things to consider. One thing to consider is if we can prevent vascular graft infections, that's always preferred than having to have to treat vascular graft infections.

So there are some preventative measures we can take and in this patient, in this scenario, we have the luxury of time. So this is an elective endovascular arterial repair. So there's several things we can do pre-op to optimize this patient for surgery and hope to prevent vascular graft infection. And some of these things listed here could be in the, as I mentioned earlier about malnutrition, ensuring this patient is nutritional and functional optimization.

And we talked about the multidisciplinary team. So this is something where possibly endocrinology or nutritionist evaluation may be helpful if we have the time. If there's any ongoing or active infection, let's say they had a diabetic foot ulcer or something like that, that'd be something you'd want to manage or optimize as best as possible. Diabetes, making sure their glucose control is under as tight of control as possible, particularly leading up to surgery.

Also, one thing in this patient's history, which comes up a lot, is this childhood allergy to penicillin. So when this person was a child, you know, they got a penicillin or amoxicillin, and their, and their mother said, you know, never take penicillin again, you're allergic to it, and now it's 70 years later.

And sure enough, a lot of data actually out of our institution, as well as others, looked at that classic history of penicillin allergy and found that that really was not a true allergy in that. You know, many of these patients, we've avoided any sort of penicillin or beta lactam based therapies. A lot of data out there that shows giving beta lactams prior to surgery, it does much better compared to non beta lactam therapy like vancomycin.

So IV cefazolin prior to surgical incision has a much better rate of preventing surgical site infections, possibly even these leading forward to potential graft infections. So this is something where either consultation with an allergist to potentially form penicillin skin testing is something to consider here.

Although even that practice is starting to change as well to where a history like this oftentimes just giving that one dose in a supervised setting pre op without even seeing allergy, having that skin test being performed, is something that a lot of centers are starting to do. So I think that's a nice area that there's a lot of data showing that beta lactam therapy is superior at preventing surgical site infections compared to something like vancomycin.

Otherwise, at this point, those are probably the best thing. So we have the luxury of time. Let's use it. Let's get this patient as optimized as possible. And one more thing, as I mentioned, the tobacco smoking, any way we can prevent that, that will be not, not just for surgical site infection, vascular graft infection, as well as, you know, downstream, all the complications from cigarette smoking.

She was started on cefazolin, has stabilized, and has a weaned off of pressors. But her Staph aureus bacteremia has persisted now for three days. So as ID consultants, we're often called to determine whether the source of Staph aureus bacteremia or really other bloodstream infections can be due to a vascular graft. So how should we approach these cases?

So when we think about the bloodstream infection in a patient who has a graft in place, we have to think whether the graft itself is a source of bloodstream infection. Is that bloodstream infection come from somewhere else and then now infected the graft? Or the bloodstream infection has just happened from somewhere else and then now the graft is still okay without infected? And sometimes it's very challenging to distinguish all of that.

Apart from the investigation that we're going to obtain in the near future, we have to think about two factors that play a part in the bloodstream infection. The first factor is that what kind of organism causing bloodstream infection. For example, from this clinical vignette, the Staph aureus bacteremia. As we all know, it's scary.

I think that this patient is in trouble because she has both pacemaker and vascular graft in place, which just recently placed months ago, which means it's very early. So the risk of infection is definitely higher than the patient who present with bacteremia in the later state of the vascular graft placement.

This patient is in trouble, but it's quite obvious that when the patient present with the Staph aureus bacteremia, we really need to look for something else like, you know, graft infection, pacemaker infection. But it might not be obvious in the case that the patient present with other type of bloodstream infection, for example, Gram negative or other Gram positive other than Staph.

Most of the time, the principle is that Staph aureus bloodstream infection has the highest risk of graft becoming infected. On the other hand, when the patient presents with urosepsis and Gram negative bacteremia, the chance of vascular graft becoming infected is relatively low compared to Gram positive. There is some in the middle risk.

For example, in a patient who has like a Strep bloodstream infection, Enterococci, or even some other type of Gram negative like Pseudomonas or Serratia, all of these fall into the middle category, which means we also need other factors to consider. For example, whether the bacteremia is prolonged, whether this is a community onset, whether we could not identify any other source, or whether the bacteremia keep persisting even though we start the treatment.

So if the patient has all of these factors, our thought about vascular graft infection, the chance of vascular graft infection need to be higher, and we also need to think that we should provide more investigation to look for the graft infection specifically. And one other point I just want to point out is early detection of the bloodstream infection in this group of patient is very important.

For example, if we have some mechanism, for example, if the stewardship team or the microbiology team can alert the provider and say that, Hey, this is a bloodstream infection. Especially in the setting of the patient has a device or vascular graft, that would be very helpful because I think the early intervention, early infectious disease consult in this scenario, provide benefit in the patient outcome.

And so this patient is considered fit for surgical intervention. You started to talk about it in the beginning, but what are the types of surgical approaches that are used to try and cure infection?

There is the curative approach, and there is the suppressive approach. So curative approach means that you have to explant and remove the entire infected graft. It needs to come out. This is source control. We love this as infectious disease physicians, right? We always want source control.

So that infected graft needs to come out and there needs to be plans for reconstruction because of course you will need to connect the proximal and distal ends again, but for cure, you have to remove the infected graft. The suppressive approach is anything other than that. So if you are not going to explant the entire graft, you are not going to cure this infection. And you can see a lot of different scenarios, right?

Sometimes that patient does not have any form of surgery, sometimes they have only debridement, sometimes they have partial resection of the graft, but then the other part of the graft is still there. So anything outside of explanting the entire graft, in our opinion, is not going to really be a curative approach.

Now, when you look at the literature, and of course, this is not going to be any high quality studies because vascular graft infection is not a very common condition, so it's not very well studied. But if you look at the literature, with the vascular graft explantation, this is a high risk procedure.

It's a very complex procedure, and mortality can be between 18 percent to 30%, even though as infectious disease providers, we want to advocate for a curative approach, and we always push for that, you know, we're not the ones who are doing the surgery, so we really have to understand the point of view of the vascular surgeons who say, you know, this patient is not a good fit for surgery because he's gonna have a very high risk of complication. So we really need to be aware of that.

But if you look at the suppressive approach in the literature there, there is actually some studies that show that mortality 100% after 2 years. So, we're saying that if you don't explant the graft and you do a suppressive approach for intracavitary vascular graft infection, specifically intracavitary, this suppressive approach is not a durable option and patients will eventually have a bad outcome. If there is any way you could advocate for a curative approach.

then that should be the way you go about it. But at the same time, we have to understand when the surgeons tell us that this patient is particularly at high risk for surgery, and I don't think I can go in and explant the graft for this patient. Okay, so that's, those are a couple of points that I wanted to make first. Now, if you come to the algorithm that we have, it mainly talks about the curative approach, right?

So there are two different pathways to explant the graft and do a curative approach. Both of these pathways actually include the explantation of the entire graft. But what distinguishes those pathways is how you're going to reconstruct after you explant. There is something called extra anatomic reconstruction, and there is something called in situ reconstruction.

What in situ reconstruction means is that they go in, they explant the entire infected graft, they debride, clean, clean, clean, remove everything that looks infected, and then they, within that same surgery, they put in a new graft, whether this is a biologic or a synthetic graft, they put it at the same time. Okay? This is in situ reconstruction. Extranatomic reconstruction means that in the reconstruction, they will bypass the infected field. And this is usually done in two stages.

Stage one, they go in, they form a bypass, and this usually is a synthetic graft for intracavitary VGIs. They do a bypass around the infected field, and then they bring the patient back a few days later for the second stage, where they resect the infected graft and debride and clean out the infection. They can't do them in the same stage because it will be a very long procedure, it will be a lot of ischemia, and the mortality rate will go up.

And now in the past, extranatomic reconstruction was kind of the preferred approach by the surgeons.

But now they are going more towards in situ reconstruction because there's data to show that in situ reconstruction actually has less complications, less mortality, better patency of the new graft, less ischemia, and even some studies showing that there is less recurrence of infection, even though it makes sense to think that extra-anatomic will have lower risk because you're bypassing the infected site. So these are the two surgical approaches within the curative category.

And there is no gold standard in the literature. It all depends on the case, the anatomy of the vascular graft that's infected, and really the surgeon's preference. So as of now, we don't have a gold standard for what surgery should be done over the other. Both of them are still being applied until today.

We have to factor that in. So, okay, so accurate microbiological diagnosis is key. And before even getting into all that, what is very important here, in addition of, hey, what's the bug, is you have to tailor this. You have to individualize this therapy for that patient with that procedure and take all the medical comorbidities into account, take into account the surgical aspect as well. As Hussam mentioned earlier, we ideally want cure, right?

I mean, I think everybody wants cure, but these are major high risk surgeries. Every patient in this group will be quite high risk and will be high risk for if they were to relapse or have a recurrence. So what I'm getting at here is this seems easy and it's like, oh, well, here's the bug. Here's the antibiotic for this long and that's it. But I always say have plan A, plan B, plan C, D, E, F in these patients. And I say that because what is it, what can go wrong, will go wrong.

Yeah, so let's put them on IV for six weeks. So right up there front, you know, IV six weeks, some cases you may have, you could go oral, but for the most part, these folks are going to be six weeks IV up front. And then what do you do after that? So after that six weeks of IV antibiotics, the question gets to, do they need to be on some form of suppressive therapy, or in other words, a prophylactic three to six months, and in some cases even up to a year depending on the graft.

But again, you have to tailor this to the individual. You have to take into account their risk of Okay, if this were to relapse or recur, what trouble are they in? What did they do at the time of surgery? Did they do in situ reconstruction and put a put a graft, a synthetic graft? Or did they put a a cryopreserved tissue graft, or do they do an ex anatomic bypass, which is going to be a synthetic? Those all factor into do I put this patient on for three to six months? Do I put them on a year?

Do I put them on lifelong? And then also the organism. So if you have something like Staph aureus, Pseudomonas, multi drug resistant pathogens, you also may consider lifelong prophylactic or suppressive therapy, depending on on how they reconstruct it. But you also have to factor in that's not always easy. So if you have Pseudomonas, well, what's your, at the, you know, for the most part, what's your oral, what's your only oral option for suppression? Cipro or Levo?

Well, what if they have a prolonged QT? Well, that kind of leaves that out. Do I put them on, uh, IV gentamicin therapy three times a week? I mean, these are things that where I was saying you kind of want to have those backup plans or contingency plans in place because something will go wrong. Now this patient in our center, in our scenario here is uh, 67. Well what if they're 35? Are you going to keep them on lifelong suppression if they're 35 with MSSA?

Sure, you could try, but at some point, either the patient's going to develop some intolerance or, you know, let's say C. diff is a complication or the bug develops resistance and now it became, you know, MRSA. Again, I'm just throwing things out there that are possibilities, but, but these are all things you have to take into account. So, again, an individualized approach to each patient. None of this is a route where you just say, okay, everybody's gonna get this, this, and that's it.

No, it's, you have to take everything into account. Their age, their comorbidities, and actually, this is where you want to do some shared decision making. This is where, you know, we talk about the multidisciplinary teams, and again, yeah, we're going to kind of be the deciding factor from an infection side, you know, antibiotics, but the patient's going to have to take this medicine for, let's say we go down the lifelong route, maybe 10, 20 years.

Do they want to be on a fluoroquinolone for 10 years. Can they even tolerate it? You know, I mean, these are just things you have to factor in. So that's why it's not just one thing out there. What we have in figure seven, kind of in the antimicrobial course, realize that this has to be individualized. It's not just, just because someone goes for in situ reconstruction with a synthetic graft, that they're all going to get this program.

I wish it was that easy, but it's actually quite the opposite. Cause then the other part to this is, well, how do we, okay, in the hospital, it's quite easy. Put them on IV antibiotics, get a PICC line in, set them up with lab monitoring and an OPAT or outpatient antimicrobial therapy monitoring, and we'll see in six weeks. Okay. Well, what happens at the six week mark?

And, and, and as I mentioned, having those contingency plans, because there will be some drug drug interactions or side effects or intolerances, and that's, we're having that robust team with pharmacists, nursing, that support in the outpatient setting is critical because once the surgery is done, these patients have

to recover and hopefully we can either prevent infection from coming back or keep it under control and suppress or hopefully cure and again, we I said the hard part was the surgery, but oftentimes the hard part is getting through those six weeks and then potentially another three to six months of oral prophylaxis or potentially lifelong suppression because, as Hussam mentioned a little while ago, some of these these infections carry high morbidity as well as high mortality.

So, we want to be as aggressive as we can be, but always keep the patient at the center of your decisions and involve them in these decisions. discuss with them. This is not easy. There's not one cookbook recipe that, okay, this works for everybody. And I kind of prepare patients that, yeah, this, you know, certain things can fail or, or you may not tolerate it. And we have to do certain things that are outside of the box a little bit.

So keep the patient focused, individualize this, talk with the surgeon. What happens if we fail? What if it's Pseudomonas and the only thing we have is IV options? Is there, what's this patient's chance of another surgical intervention? Let's say they went for a suppressive route. Perhaps, you know, does this patient need to go for an extra anatomic reconstruction?

But if you, you know, the surgeon may say that's not possible, you know, it's so high risk, you know, it's not even So these are just things you, you gotta take all this into account because like I said, some of these decisions can be, they're, they're not easy and can be quite complex. Multidisciplinary team comes up quite often at this, you know, post surgery, a lot of times it's, it's a lot of discussions, a lot of close follow up to hopefully have, have success for this patient.

So yeah, those are tough conversations. And again, this is, this is complex to us. So us trying to to translate this to our patients, to understand that the gravity of the situation, I think is important to do that because again, well, why do we want to put you on an antibiotic for the rest of your life? Well, there's some bad stuff that can happen if we don't. But again, just having these discussions throughout the process is very important.

The patient is hemodynamically stable, so antibiotics are held. The patient goes for a percutaneous aspiration and then from that is shown to have purulent fluid which yielded polymicrobial growth and cultures. So vascular surgery and ID are involved. How would you talk about approaching this case?

So when we think about the Samson classification, it's divided into like five categories. The 1 and 2, skin and soft tissue infection around the graft that is not involved in the graft itself. When we talk about the graft infection, we talk about Samson 3, 4, and 5. So, 5 is the extreme, which means the patient is septic, has a bleeding, has a bacteremia.

That's a SAMSON 5. And then SAMSON 3 and 4, uh, the category that graft is involved, but it also depends on whether it involves anatomosis or not, that would be SAMSON 3 and 4. In this category, I think the patient falls into category of SAMSON 3 and 4, because she has been hemodynamically stable, and we know that there's a fluid collection around the graft. So the reason why we want to know about the Samson category, because that would affect our management.

For example, the, the Samson 1 and Samson 2, we usually do like aggressive debridement with the antibiotic because the infection is not involved in the graft, so we don't need to do any surgical approach. But when we talk about the Samson 3, 4, and 5, that's when the graft involvement, that's the reason why we also have a thought process the same way as the Sampson 1.

When we're dealing with the intracavitary, which means are we doing surgical management, like for curative purpose, or we do the suppressive strategy, which I think the thought is the same.

So when we talk about the SAMSON 3 and 4, we can either do debridement with preserve the graph, or we can do the debridement plus doing the surgical approach to exchange the graft, and then all of that, most of the time, the patient like this will need multiple debridement and muscle flap and prolonged antibiotic course, the same as Hussam and Dan mentioned.

Let's say if the patient has like Samson 3 and 4 and they have like the easy to treat organism, sometimes the vascular surgeon will do the graft preservation, which means doing multiple debridement. Plus the antibiotic therapy for, you know, four to six weeks of IV followed by the oral suppression for three to six months in when we run into the easy to treat organism.

When I say the easy to treat, mean the organism that is not fall into the category of, you know, Staph aureus, MRSA, Pseudomonas, or MDRO, or the multi drug resistant organism. All of those most of the time we will need a surgical approach to, you know, remove the graft and exchange and everything like that, followed by the prolonged antibiotic therapy. And again, this kind of case is very, very complicated, even with the infectious disease itself.

So I think it is very important to involve multidisciplinary team. As Hussam mentioned that we are not the one who, you know, actually do the surgery. So we need to talk to the expert in this scenario and come up with a multidisciplinary conclusion to say that, okay, this patient may be suitable for this approach. This patient may need graft preservation, followed by the antibiotic, which requires multiple discussion and also multiple factor that need to take part in the discussion.

And also, I think the patient preference is also the one that sometimes we, we didn't involve them because we think that, okay, we managed this after Samson 3, 4, 5. And when we talk to the patient, sometimes the patient say that, no, I don't want anything done or something like that. So I think patient centered decision is also very important in this situation.

What we can do and what we have done in the paper is we listed at least one that we think is a very important factor, uh, where disparities could be seen. I'm hoping now towards the end of the podcast between myself, Dan, and Mac, we have already kind of highlighted the just extensive resources needed to take care of the patient. Itv truly needs like a village. What's the saying? Need a village to take care, to raise a child. It needs a village to take care of the patient as well.

We have, you know, if you look at the review, we have mentioned almost everyone in the hospital and how everyone can have a role. We talked about surgeons, physicians, including specialists, and including hospitalists. We talked about social workers, nurses, pharmacists, OPAT, antimicrobial stewardship, and microbiology labs. So really extensive resources. And so do we expect that every hospital has those resources available? Of course not.

There are certain centers that are able to provide this type of service. And so, the disparity here is access to this care, right? There is a lot of reasons why some patients might not be able to access this care. For example, your zip code, right? It's just a simple, you know, idea, right?

The zip code of the patient can actually determine whether or not this patient is able to get access to the specialized care because not everyone lives somewhere that has a big hospital next to them that's able to do things like that. Access to specialized care is very, very important and, you know, how do we centralize this care? How do we refer those patients immediately or as soon as possible to those big centers? That is actually the trick.

That is one of the major health care disparity and we kind of spoke again about the minimum capabilities that a center has to have in order to provide care. If that's not available, then really there should be efforts made to transfer the patient soon enough to a larger hospital. I can give you more examples about things that I think are important in this patient population. If you think about it, this is again a very complex condition and it actually requires a lot from the patient himself.

You know, if you go back to that graphic abstract, we said that the patient was one of those three bubbles that was highlighted with dark blue because they really need to, to steer the ship. They need to be engaged in their care. They need to know what's going on. There is going to be a lot of treatment plans, follow up labs, and all of that. So the patient really needs to know what's going on.

And so you think about patient education, you think about patient language barrier, and those things are additional stuff that could come in the way, right? And I think You know, unfortunately, as physicians become more and more busy, I don't think that we are making, you know, we're not, we're doing a good job educating those patients properly. You know, physicians need to know that they need to give them more time. There should be an interpreter.

And even if the interpreter is with you in the room, you need to repeat what you've been saying to the patient. You need to give, just give them more time, make sure that they understand what's going on before they get out of the hospital and that there is a way for them to actually follow up with the care teams. So these are kind of some of the things that I can think of and that we have observed when we've taken care of those patients.

Everything else that we know about social determinants of health and how they affect other complex conditions will probably also be applied applicable to, to vascular graft infections.

And we are already seeing that in referral centers. We, we see a lot of vascular graft infections. So, and those are likely going to increase. So, I think we have to make all efforts that we can in order to talk more about this topic so that physicians are more aware of it.

This is one of the reasons why we were even interested in making such a review, to kind of describe this topic because we think that it's going to be become more prevalent in the future as more and more patients undergo those procedures.

I need to talk to multiple people and I would encourage when we get consult about this very complex scenario, talk to your colleagues, talk to other people who often see this condition because I think it's very, very complicated and require, you know, the whole village to take care of the patient. One last thing is that I just want to also shout out to the co author who helped writing this paper, who didn't join the podcast this morning.

Our paper also involves collaborative effort from pharmacy, from vascular surgery, from multiple people who helped writing this paper, I just want to say thank you to all of them.

So, instead of having a big, large incision midline, now this can be performed with an incision in the groin region. So, instead of having these big, large incisions where the risk of the surgery definitely goes up, I mean, as I said, all these vascular surgery interventions are high risk, but open surgical repair versus endovascular repair has revolutionized this process of aneurysm repair. So what do I mean by that? Why do I say that?

Is patients that may have been deemed too high risk, too sick to go for open surgical repair, are now being considered for endovascular repair. So think of this in the realm of TAVR, transcatheter arterial valve repair, where some patients were too high risk to go for open cardiac surgery, but they're not too sick to replace a valve through the patient's wrist or through the groin region. Compare that to vascular repair, even in emergent cases, as well as elective cases.

Patients, as well as surgeons are starting to opt more towards endovascular repair compared to open surgical repair, which also opens up, broadens the pool of folks who would have been deemed, as I mentioned, too high risk or too sick to go for aneurysm repair, open surgical repair, who are now, you know, the risk is not that high to where they can undergo endovascular repair. So, so what happens there is you have patients with higher medical comorbidities, or air quotes, sicker.

So the population is changing. So as Hussam mentioned, we're going to see more vascular graft infections, and I think he's right on that, but I will say that we do see a lower rate of graft infections with endovascular repair or replacement versus open surgical repair. However, that pool of patients with more comorbidities, the worry there would be, yes, even though the procedure itself has a lower risk of infection and the grafts that are repaired that way have a lower risk.

However, the patient and their comorbidities being so high that changing in the pool risk could potentially lead to an increased infection. But again, that's what the, we'll see where things are in the next five to 10 years and on that, but, but I think Hussam is correct in that regard. So that's something else to keep in mind is that the surgical approach has changed. Therefore the pool or population is, is going to change as well.

And ultimately, you know, I think if anything you've heard us say is throughout this podcast is individualized approach. Each patient come up with a plan with not just yourself, with a, with a multidisciplinary team of what's best for your patient at that moment in time and be flexible, involve them in the decision making, keep them in the center of that decision. In the end, that doing what's best for the patient, I think that's the best route here.

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