MRSA-infected external iliac artery pseudoaneurysm treated with endovascular stenting

Fatal arterial hemorrhage after pancreaticoduodenectomy: How do we simultaneously accomplish complete hemostasis and hepatic arterial flow?

BACKGROUND

Although arterial hemorrhage after pancreaticoduodenectomy (PD) is not frequent, it is fatal. Arterial hemorrhage is caused by pseudoaneurysm rupture, and the gastroduodenal artery stump and hepatic artery (HA) are frequent culprit vessels. Diagnostic procedures and imaging modalities are associated with certain difficulties. Simultaneous accomplishment of complete hemostasis and HA flow preservation is difficult after PD. Although complete hemostasis may be obtained by endovascular treatment (EVT) or surgery, liver infarction caused by hepatic ischemia and/or liver abscesses caused by biliary ischemia may occur. We herein discuss therapeutic options for fatal arterial hemorrhage after PD.

AIM

To present our data here along with a discussion of therapeutic strategies for fatal arterial hemorrhage after PD.

METHODS

We retrospectively investigated 16 patients who developed arterial hemorrhage after PD. The patients’ clinical characteristics, diagnostic procedures, actual treatments [transcatheter arterial embolization (TAE), stent-graft placement, or surgery], clinical courses, and outcomes were evaluated.

RESULTS

The frequency of arterial hemorrhage after PD was 5.5%. Pancreatic leakage was observed in 12 patients. The onset of hemorrhage occurred at a median of 18 d after PD. Sentinel bleeding was observed in five patients. The initial EVT procedures were stent-graft placement in seven patients, TAE in six patients, and combined therapy in two patients. The rate of technical success of the initial EVT was 75.0%, and additional EVTs were performed in four patients. Surgical approaches including arterioportal shunting were performed in eight patients. Liver infarction was observed in two patients after TAE. Two patients showed a poor outcome even after successful EVT. These four patients with poor clinical courses and outcomes had a poor clinical condition before EVT. Fourteen patients were successfully treated.

CONCLUSION

Transcatheter placement of a covered stent may be useful for simultaneous accomplishment of complete hemostasis and HA flow preservation.

Iliaco-enteric fistula after robot-assisted comprehensive surgical staging of endometrial cancer: a case report

Fistula formation between bowel and blood-vessel is a very rare complication after intraabdominal surgery. We report a case of iliaco-enteric fistula following robot-assisted surgical staging of endometrial cancer. A 71-year-old woman subjected to comprehensive endometrial cancer staging presented with hematochezia 35 days postoperatively. A retroperitoneal right-sided abscess and an iliaco-enteric fistula was confirmed upon imaging. The patient received endovascular repair of the aneurysm in her right common iliac artery and the segments of the small bowel containing the fistula were resected via laparotomy. If a patient presents with new onset postoperative hematochezia after pelvic and/or paraaortic lymphadenectomy, fistulation between bowel and the major abdominal blood vessels should be part of the differential diagnoses.

Pseudoaneurysm rupture with hemorrhagic shock in a patient with periprosthetic hip joint infection: A case report

RATIONALE

Although pseudoaneurysm (PA) formation following primary and revision total hip arthroplasty (THA) is rare, PA rupture may lead to severe complications that can result in a threat to life and limb.

PATIENT CONCERNS

A 65-year-old man presented with acute hemorrhagic discharge for one day from the chronic hip sinus secondary to revision THA that had been performed 6 years ago, for which he had received multiple courses of debridement, antibiotics, and implant retention procedures owing to periprosthetic joint infection (PJI).

DIAGNOSES

Radiographs showed septic loosening of both the femoral and acetabular components, with medial migration of the component beyond Kohler's line. Contrast-enhanced computed tomography angiogram of the abdomen and pelvis of the patient demonstrated a large PA of the right external iliac artery (EIA), measuring 6.1 cm × 7.7 cm in diameter and 9.1 cm in length.

INTERVENTIONS

A ball-shaped antibiotic-loaded cement spacer (ALCS) was used to tamponade a bleeding PA, treat the coexisting PJI, and thus facilitate endovascular stent-graft repair (ESGR) later on.

OUTCOMES

The ESGR resulted in complete exclusion of the PA and successfully controlled the bleeding. The patient underwent a successful revision THA 6 months after stent insertion. Neither stent-graft infection nor recurrent PJI were detected at 18 months.

LESSONS

Given the potential of a PA for causing significant morbidity and mortality, the surgeon should have an elevated index of suspicion in the presence of intrapelvic migration of the acetabular component. While facing a PA rupture with/without hemorrhagic shock in patients with coexisting hip PJI, ALCS ball implantation and subsequent ESGR might be an effective method to save the patient's life and limb.

Emergency Hybrid Approach to Ruptured Femoral Pseudoaneurysm in HIV-positive Intravenous Drug Abusers

BACKGROUND

Chronic traumatism of the common femoral artery due to intravenous injection in drug abusers, in association with local infections and arterial wall weakening caused by human immunodeficiency virus (HIV), can lead to the development of pseudoaneurysms (PSAs). Rupture of PSA is a dramatic event in such patients, and its correction is difficult and controversial. Most of the cases reported describe open surgical elective options, which consist in ligation, repair, or substitution of the damaged arterial segment, using when possible biological grafts. In literature, few cases describe an endovascular repair with covered stent deployment.

METHODS

We present 2 cases of HIV-positive intravenous injection in drug abusers who needed emergency treatment for active bleeding in ruptured PSA of the right common femoral artery. In both cases, under general anesthesia needed for lack of patient's compliance and unstable hemodynamics, a short dissection to the distal superficial femoral artery was required.

RESULTS

Then, maintaining a manual compression on the bleeding site to stop hemorrhage, we deployed a covered stent graft in the site of the arterial breakdown through a retrograde approach.

CONCLUSIONS

The favorable results and progressive healing of wound and local infections persuaded us not to perform any further surgical correction. The absence of recurrences and late complications, after 3 years in the first case and 1 year in the second one, lead us to consider this hybrid endovascular approach as a valuable alternative to open surgery in HIV intravenous injection in drug abuser patients, in particularly when emergency conditions occur.

Infected Iliac Pseudoaneurysm after Cardiac Catheterization Complicated by Girdlestone Pseudoarthroplasty for Recurrent Infection of Hip Prosthesis

We report a massive infected pseudoaneurysm of the right external iliac artery in the setting of Girdlestone pseudoarthroplasty (GSA) for chronic infection. Around the time of her GSA, the patient underwent cardiac catheterization with resultant pseudoaneurysm formation. Infection was likely due to spread from her previous chronic infection. Delay in presentation occurred due to attribution of her symptoms to her GSA. The patient underwent ligation of the right external iliac artery and hip disarticulation and was discharged on antibiotics. At follow-up, she had significantly reduced pain. Although vascular complications from orthopedic procedures are well described, this case seems to have been caused by secondary infection of her iatrogenic external iliac artery pseudoaneurysm.

Deep Leg Vein Reconstruction for an Isolated Mycotic Common Iliac Artery Aneurysm in an HIV-Positive Patient

Isolated mycotic common iliac artery aneurysms are rare, and as such, there is no consensus opinion on management. Traditional surgical options include resection with extra-anatomic bypass, placement of allograft or antibiotic treated synthetic graft, or autogenous vein reconstruction. We report the case of a 46-year-old, human immunodeficiency virus-positive male who presented with a recurrent pneumonia and new onset of right lower quadrant abdominal pain associated with right lower extremity swelling. computed tomographic scan revealed an isolated 9.5 cm right common iliac artery aneurysm with no evidence of rupture. Preoperative blood cultures grew out Streptococcus pneumoniae. Operative repair included aneurysm resection and reconstruction using an autogenous femoropopliteal vein interposition graft from the ipsilateral thigh. The patient had an uneventful recovery with resolution of his lower extremity swelling and a normal duplex exam at follow-up. Large mycotic common iliac artery aneurysms can be successfully treated with aneurysm resection and reconstruction using an autogenous femoropopliteal vein conduit. This technique obviates the need for extra-anatomic bypass or other forms of reconstruction using prosthetic material.

Ruptured mycotic common femoral artery pseudoaneurysm: fatal pulmonary embolism after emergency stent-grafting in a drug abuser

The rupture of a mycotic femoral artery pseudoaneurysm in an intravenous drug abuser is a limb- and life-threatening condition that necessitates emergency intervention. Emergency stent-grafting appears to be a viable, minimally invasive alternative, or a bridge, to subsequent open surgery. Caution is required in cases of suspected concomitant deep vein thrombosis in order to minimize the possibility of massive pulmonary embolism during stent-grafting, perhaps by omitting stent-graft postdilation or by inserting an inferior vena cava filter first. We describe the emergency endovascular management, in a 60-year-old male intravenous drug abuser, of a ruptured mycotic femoral artery pseudoaneurysm, which was complicated by a fatal pulmonary embolism.

Stent-graft placement with early debridement and antibiotic treatment for femoral pseudoaneurysms in intravenous drug addicts

PURPOSE

Explore the application of endovascular covered stent-graft (SG) placement in femoral pseudoaneurysms in intravenous drug addicts.

MATERIALS AND METHODS

We evaluated a consecutive series of pseudoaneurysm in intravenous drug addicts treated with SGs from August 2010 to December 2013.

RESULTS

15 patients with 16 arterial pseudoaneurysms were enrolled in this study. All were males with a mean age of 36.9 years. Hemorrhage was the most common reason (93.8 %) for seeking medical care, and 3 of these patients were in hemorrhagic shock at admission. All patients received broad-spectrum antibiotics, and debridement and drainage were implemented after SG placement. 7 of the 13 cases which had microbiologic results showed mixed infections, while gram-negative bacteria were the major pathogens. Except for 2 patients, who were lost to follow-up, two new pseudoaneurysms formed due to delayed debridement, and one stent thrombosis occurred, none of the remaining cases had SG infection or developed claudication.

CONCLUSIONS

SG placement controls massive hemorrhage rapidly, gives enough time for subsequent treatment for pseudoaneurysms due to intravenous drug abuse, and reduces the incidence of postoperative claudication. With appropriate broad-spectrum antibiotics and early debridement, the incidence of SG infection is relatively low. It is an effective alternative especially as temporary bridge measure for critical patients. However, the high cost, uncertain long-term prospects, high demand for medical adherence, and the risk of using the conduits for re-puncture call for a cautious selection of patients. More evidence is required for the application of this treatment.

Delayed infrarenal aortic pseudoaneurysm treated by endovascular stent graft in pyogenic spondylitis

A 61-year-old male patient with pyogenic spondylodiscitis and epidural and psoas abscesses underwent posterior decompression, debridement, and instrumented fusion, followed by anterior debridement and reconstruction. Sudden onset flank pain was diagnosed 7 weeks postoperatively and was determined to be a pseudoaneurysm located at the aorta inferior to the renal artery and superior to the aortic bifurcation area. An endovascular stent graft was applied to successfully treat the pseudoaneurysm. Postoperative recovery was uneventful and infection status was stabilized.

Gram-negative groin sepsis treated with covered stents and systemic antibiotics

Prosthetic graft infections are hazardous conditions. Those due to Gram-negative bacteria are particularly serious. When Gram-negative microorganisms are present, entire graft excision is recommended, with revascularization if needed, preferably with autogenous tissues or with prosthetic grafts via non-infected planes if autogenous options are not available. We herein report the case of a diabetic man with critical limb ischemia, who after lower-extremity revascularization with a prosthetic graft, developed an early graft infection due to Gram-negative and fungal organisms, and who was successfully treated with a covered stent placed across grossly infected tissues. A discussion on the pertinent literature is also offered.

Emergency stent grafting after unsuccessful surgical repair of a mycotic common femoral artery pseudoaneurysm in a drug abuser

Mycotic false aneurysm caused by local arterial injury from attempted intravenous injections in drug addicts remains a challenging clinical problem. The continued increase in drug abuse has resulted in an increased incidence of this problem, particularly in high-volume urban centres. In the drug-abusing population, mycotic arterial pseudoaneurysms most often occur because of missed venous injection and are typically seen in the groin, axilla, and antecubital fossa. Mycotic aneurysms may lead to life-threatening haemorrhage, limb loss, sepsis, and even death. Any soft-tissue swelling in the vicinity of a major artery in an intravenous drug abuser should be suspected of being a false aneurysm until proven otherwise and should prompt immediate referral to a vascular surgeon for investigation and management. We report a case of rupturing mycotic pseudoaneurysm of the left common femoral artery treated by surgical resection followed by vessel reconstruction with autologous material. Unfortunately, at the time of discharge a sudden leakage from the vein graft anastomosis occurred, with subsequent massive bleeding, and required emergent endovascular covered stenting. To the best of our knowledge, this is the first reported case of femoral artery bleeding in a drug abuser treated by stent graft placement.

Local Tissue Coverage for the Management of Exposed Endografts

This case report describes the use of local tissue coverage for the treatment of surgically exposed endografts. In two cases, an endograft used for the treatment of a pseuodaneurysm was visualized through the arterial defect during open surgical evacuation of an abscess in one case and a sterile hematoma in the second case. Obtaining arterial control to remove the endograft was prohibitive owing to the anatomic location and extensive scarring and inflammation. The endografts were preserved and hemostasis was maintained by using a vein patch in one case and a local muscle flap in both cases. Both cases have had satisfactory short-term follow-up (4–12 months). An exposed endograft represents a rare and challenging problem. Local tissue coverage offers a feasible strategy for maintaining hemostasis and avoiding a potentially morbid surgical dissection. Although the short-term results of this approach have been encouraging, the long-term consequences remain unknown.

Endovascular repair of a ruptured mycotic aneurysm of the common iliac artery

This report describes the case of a ruptured mycotic aneurysm of the left common iliac artery, successfully treated with endovascular stent-grafting. A 64-year-old woman underwent diagnostic coronary angiography complicated by an infected hematoma of the left groin. Seven days later, she developed methicillin-resistant Staphylococcus aureus septicemia and CT scan evidence of perivascular inflammation around the left common iliac artery. This was followed by rupture of a mycotic aneurysm of the left common iliac artery. The lesion was successfully treated with a stent-graft and prolonged antibiotic therapy, and the patient remains free of infection 10 months later. Accumulating evidence suggests that endovascular repair can be used safely for the repair of ruptured infected aneurysms.

Endovascular treatment of bleeding external iliac artery pseudo-aneurysm following control of haemorrhage with Sengstaken tube during revision total hip arthroplasty

We report a case of false aneurysm of the external iliac artery and compression of the external iliac vein, which subsequently caused deep venous thrombosis in a 63-year-old female patient with a revised total hip arthroplasty. This is the first case of control of life-threatening intraoperative haemorrhage of an external iliac pseudo-aneurysm by Sengstaken tube which allowed time for successful management of the external iliac artery pseudo-aneurysm with endovascular covered stent. Recognition of delayed vascular injury following revision of total hip arthroplasty and the need of pre-operative imaging should be considered in revision hip arthroplasty.

Endovascular Repair of a Primary Iliac-Cecal Fistula Presenting with Gastrointestinal Hemorrhage

We report a case of an arterio-enteric fistula between an external iliac artery aneurysm and otherwise healthy cecum, presenting with torrential hemorrhage per rectum in an 85-year-old patient. Whilst fistulization to the aorta and common iliac arteries has been reported, to our knowledge no previous cases of primary fistulization between an external iliac aneurysm and normal cecum have been. Successful endovascular exclusion of the aneurysm was undertaken with a Wallgraft covered stent and the patient remains well at 1 year.

Emergency Stenting of a Ruptured Infected Anastomotic Femoral Pseudoaneurysm

A 74-year-old man presented with a ruptured infected anastomotic femoral pseudoaneurysm. Due to severe medical comorbidities he was considered unsuitable for conventional surgical management and underwent an emergency endovascular repair with a balloon-expandable covered stent. The pseudoaneurysm was excluded successfully and the patient had an uneventful postoperative recovery with long-term suppressive antimicrobials. He remained well for 10 months after the procedure with no signs of recurrent local or systemic infection and finally died from an acute myocardial infarction. To our knowledge, emergency endovascular treatment of a free ruptured bleeding femoral artery pseudoaneurysm has not been documented before in the English literature. This case illustrates that endovascular therapy may be a safe and efficient alternative in the emergent management of ruptured infected anastomotic femoral artery pseudoaneurysms when traditional open surgery is contraindicated.

Endovascular PTFE-Covered Stent for Treatment of an External Iliac Artery Pseudoaneurysm in the Presence of Chronic Infection

A 75-year-old woman with an external iliac artery pseudoaneurysm, thought to have resulted from a chronic loosening and infection of a total hip replacement, was successfully treated by placement of a covered endoluminal stent.

Treatment of secondary stent-graft collapse after endovascular stent-grafting for iliac artery pseudoaneurysms

We report the case of a patient who developed an asymptomatic pseudoaneurysm in the left external iliac artery after transplant nephrectomy. The pseudoaneurysm most probably arose as a suture aneurysm from the external iliac artery after removal of the graft renal artery. Obviously we can not exclude the possibility it was a true aneurysm, although this seems much less likely. The pseudoaneurysm was detected during a routine CT scan and was treated interventionally with a stent-graft. One month later the asymptomatic patient underwent a vascular ultrasound examination including color Doppler, power Doppler, and B-flow as a routine control. An endoleak with collapse of the stent-graft was diagnosed. There was no evidence of stent infection. At a reintervention, the pseudoaneurysm was successfully treated using two uncovered Palmaz stents at the proximal and distal edge of the stent graft. Peri- and post-interventional ultrasound and CT angiography confirmed the exclusion of the aneurysm without an endoleak.

Late Infected Pseudoaneurysm Formation after Uneventful Iliac Artery Stent Placement

Percutaneous transluminal angioplasty and endovascular stent placement are becoming common techniques for iliac artery stenosis and obstruction that are intended to reduce the need for surgical bypass procedures. The usual complications include acute or subacute thrombosis, distal embolization, dissection, and extravasation. Although stent infection is very rare after stent replacement, it is reportedly associated with a high risk of morbidity and mortality, and the use of prophylactic antibiotics should be considered. We present a case of rupture of an infected pseudoaneurysm at the site of the external iliac artery that occurred 4 months after an uneventful percutaneous transluminal angioplasty and stent placement.

Endovascular treatment of ruptured iliac aneurysm previously treated by endovascular means

A patient with a ruptured iliac aneurysm was admitted to the Emergency Department in hypovolemic shock. He had previously undergone surgical treatment for an infrarenal abdominal aortic aneurysm, which was managed with a terminal-terminal Dacron tube graft. Subsequently, he developed two iliac aneurysms, which were treated endovascularly with two wall-grafts in the right and one wall-graft in the left iliac arteries. He suffered chronic renal failure and arterial hypertension. Contrast-enhanced computed tomography showed rupture of the right iliac aneurysm and dislocation of the two wall-grafts. He was treated in an emergency situation with the implantation of an iliac endograft that bridged the two wall-grafts, which resulted in hemostasis and stabilization of his condition. Five days later, in an elective surgical situation, he was treated with the implantation of an aorto-uni-iliac endograft combined with a femoral-femoral bypass. He was discharged 5 days later in good condition. At the 4 year follow-up visit, the endoprosthesis remained in place with no evidence of an endoleak. In conclusion, overlapping of endografts should be avoided, if possible. Strict surveillance of the endovascularly treated patient remains mandatory.

Endovascular Treatment for an Iliac Artery–Ureteral Fistula with a Covered Stent

Iliac artery-ureteral fistula (IAUF) is a rare entity that has a potential risk of life-threatening hemorrhage. It is difficult to diagnose and treat appropriately. Conventional treatment for the disease consists of surgical ligation and vascular reconstruction or coil embolization. Surgical treatment is usually difficult for patients with several risk factors. In recent years, endovascular stent-graft treatment for iliac artery pseudoaneurysm has been reported. The present report describes two cases in which endovascular covered stent-graft treatment was successfully applied to treat IAUF, with good clinical outcomes.

Endovascular management of hepatic artery pseudoaneurysm hemorrhage complicating pancreaticoduodenectomy

Gastrointestinal bleeding is a morbid complication of pancreaticoduodenectomy. Determining its etiology is often a daunting challenge in that both common and unusual mechanisms may be operative. Visceral artery pseudoaneurysms, although rare, must be considered in that minimally invasive means are available for effective therapy. Our recent experience with two cases highlights the importance for both general and vascular surgeons to be aware of the diagnostic and therapeutic role for early angiography and deployment of endovascular techniques to achieve a successful outcome.