WHAT THIS PAPER ADDSThere is no universally accepted aortic graft infection case definition and clinical approaches to this complex condition differ widely with variable outcomes. Here, the Management of Aortic Graft Infection Collaboration (MAGIC), involving clinicians from several English hospital National Health Service Trusts with large vascular services, propose a formal case definition, derived by a process of multidisciplinary, expert consensus. The definition is readily applied in routine practice and aids early recognition. Importantly and towards development of evidence-based clinical guidelines that are presently lacking, it provides a consistent diagnostic standard, essential for clinical trial design and meaningful comparison between diagnostic and therapeutic strategies.Objective/Background: The management of aortic graft infection (AGI) is highly complex and in the absence of a universally accepted case definition and evidence-based guidelines, clinical approaches and outcomes vary widely. The objective was to define precise criteria for diagnosing AGI. Methods: A process of expert review and consensus, involving formal collaboration between vascular surgeons, infection specialists, and radiologists from several English National Health Service hospital Trusts with large vascular services (Management of Aortic Graft Infection Collaboration [MAGIC]), produced the definition. Results: Diagnostic criteria from three categories were classified as major or minor. It is proposed that AGI should be suspected if a single major criterion or two or more minor criteria from different categories are present. AGI is diagnosed if there is one major plus any criterion (major or minor) from another category. (i) Clinical/surgical major criteria comprise intraoperative identification of pus around a graft and situations where direct communication between the prosthesis and a nonsterile site exists, including fistulae, exposed grafts in open wounds, and deployment of an endovascular stentgraft into an infected field (e.g., mycotic aneurysm); minor criteria are localized AGI features or fever 38 C, where AGI is the most likely cause. (ii) Radiological major criteria comprise increasing perigraft gas volume on serial computed tomography (CT) imaging or perigraft gas or fluid ( 7 weeks and 3 months, respectively) postimplantation; minor criteria include other CT features or evidence from alternative imaging techniques. (iii) Laboratory major criteria comprise isolation of microorganisms from percutaneous aspirates of perigraft fluid, explanted grafts, and other intraoperative specimens; minor criteria are positive blood cultures or elevated inflammatory indices with no alternative source. Conclusion: This AGI definition potentially offers a practical and consistent diagnostic standard, essential for comparing clinical management strategies, trial design, and developing evidence-based guidelines. It requires validation that is planned in a multicenter, clinical service database

Surg 2009;xx:xx-xx.Objectives: To update our previous systematic review of outcomes following synchronous carotid endarterectomy (CEA) and off-pump coronary artery bypass grafting (OFF-CABG).Design: A systematic review of operative risks reported in published studies of synchronous CEA plus OFF-CABG procedures.Results: We identified 12 eligible studies, including data on 324 synchronous CEA plus OFF-CABG procedures. Operative mortality was 1.5% (95% confidence interval (CI): 0.3-2.8), the risk of death or ipsilateral stroke was 1.6% (0.4 -2.8%), risk of death or any stroke was 2.2% (95% CI: 0.7-3.7) and the risk of death, stroke or myocardial infarction was 3.6% (95% CI: 1.6 -5.5).Conclusions: Limited published data on 324 patients suggest that early outcomes after synchronous CEA plus OFFCABG are better than those following staged or synchronous CEA plus CABG where the cardiac procedure was performed on-pump. This may, however, be attributed to publication bias, case selection or the fact that the aorta was not manipulated or cannulated, rather than CEA being primarily responsible for the lower stroke risk. Colleagues with unpublished experience of CEA plus OFF-CABG are encouraged to submit their data to further inform the debate.

Objective: We report the uptake, length of stay and vascular readmission rates of carotid endarterectomy (CEA) and CAS among patients with symptomatic or asymptomatic carotid artery disease in the English National Health Service (NHS).Methods: Retrospective cohort study based on routinely collected Hospital Episode Statistics (HES) inpatient data. We identified individual admissions for CEA (n = 15996) or CAS (n = 632) between 2006 and 2009. Summary data were used to describe procedure volumes between 2009 and 2012. We analysed trends in procedure use over time and used ordinary least squares regression to evaluate patient, clinical and organisational characteristics associated with longer length of stay for revascularisation.Results: CAS made up less than 5% of carotid revascularisation procedures; there was no trend for increasing use between 2006 and 2012. Patients treated with CAS were on average younger, lived in areas of higher deprivation and were more likely to have amaurosis fugax or a comorbidity of heart disease. CAS patients had a 19% (95% CI 14-24) shorter stay in hospital than CEA patients.Conclusion: Despite the early promise of CAS and numerous randomised controlled trials evaluating efficacy, it has not been rapidly adopted in England. Cautious adoption may be appropriate given the higher periprocedural risk of stroke or death after CAS, particularly in recently symptomatic patients.

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