Aortic Endograft Infection After COVID-19: A Single-Centre Case Series and a Proposed Descriptive Clinical–Radiological PET/CT Staging Framework

Background: Aortic endograft infection (AEI) after endovascular aneurysm repair (EVAR) is rare but life-threatening. The Management of Aortic Graft Infection Collaboration (MAGIC) criteria define infection, but there is no standard way to report the extent of infection. We describe patients who developed AEI after coronavirus disease 2019 (COVID-19) and propose a descriptive clinical–radiological PET/CT staging framework. Methods: Retrospective, single-centre case series of EVAR patients who underwent [18F] fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) between 2020 and 2023. Six index patients (Group A) were managed for AEI after PCR-confirmed COVID-19. Five reference patients without COVID-19, imaged during the same period for suspected infection at another site (Group B, n = 2) or malignancy (Group C, n = 3), were included to describe endograft uptake in the absence of AEI; they were not matched controls. Each patient was classified according to MAGIC, with the finding supporting each criterion recorded. Each endograft was assigned a descriptive clinical–radiological stage (0–III): Stages 0–II were defined by PET/CT uptake pattern and anatomical extent, and Stage III by an additional imaging-defined (e.g., endograft limb thrombosis) or clinical (sepsis) complication, recorded separately. Results: Mean age was 76 years (9 men). Of the six index patients, one (Case 6, organism cultured from the explanted endograft) met the MAGIC definition of diagnosed AEI and five met that of suspected AEI. All six presented with fever, and every index patient had at least one additional source of bacteraemia or cause of immunosuppression, including corticosteroids given for COVID-19 pneumonia. Five had iliopsoas abscess. Four index endografts were classified as Stage III (clinical complication, sepsis, in all four; imaging-defined complication, endograft limb thrombosis, also in one) and two as Stage II; all five reference endografts were Stage 0. The median interval from COVID-19 to AEI diagnosis was 14 months (IQR 10–16), and from EVAR to PET/CT 15 months (IQR 4–35). Three index patients died (two infection- or aorta-related), and all three Group C patients died of malignancy progression. Conclusions: This case series describes late AEI, frequently with iliopsoas involvement, in patients with prior COVID-19 and multiple other risk factors. The design does not permit any conclusion as to whether COVID-19 contributes to endograft infection. The proposed descriptive clinical–radiological PET/CT framework may help standardise the reporting of disease extent alongside MAGIC-based diagnosis but requires validation in larger, independent cohorts before any diagnostic or therapeutic use.