Infection of endovascular stents: an uncommon but important complication

Remote endarterectomy to remove infected Viabahn stent-graft

Infection of peripheral arterial vascular grafts and stent-grafts represents a complex surgical scenario, with a number of proposed management strategies. Surgical removal of infected material with adjunctive arterial reconstruction is often required. However, surgical removal is often difficult and complex. This case study demonstrates an infected Viabahn stent-graft between the external iliac artery and the superficial femoral artery, with arterial autolysis of the common femoral artery and proximal superficial femoral artery, in which a hybrid technique combining remote endarterectomy and surgical debridement was used to remove the infected stent-graft.

Aortic Graft Infection: Update on Management and Treatment Options

Replacement of the abdominal aorta, whether by autogenous or prosthetic conduit, has been an a priori requisite in the vascular surgeon's armamentarium since its technical feasibility was described in the early 1950s. The Achilles' heel of this operation, in spite of the progress made over the last half century, is still, however, aortic graft infection. Though survival and limb salvage rates have improved over time—commensurate with advances in surgical technique, critical care, and antimicrobial agents—the prevention and treatment of aortic graft infection remains a formidable challenge to the vascular surgeon. The authors herein review the current literature on this topic with an emphasis on the surgical management options available and suggest an individualized operative strategy based on patient as well as microbial factors to attain the best possible outcome.

Spontaneous rupture of superficial femoral artery repaired with endovascular stent-grafting with use of rendez-vous technique, followed by delayed infection

This is the case of a 72-year-old man with lower limb ischemia due to spontaneous rupture of nonaneurysmal superficial femoral artery that developed into thigh hematoma. After failure of a Fogarty revascularization, an emergency endovascular procedure was performed to restore the arterial continuity. A rendezvous procedure was performed with a double femoral and popliteal approach and two covered stent-grafts were deployed. Patient's clinical conditions immediately improved, but 4 months later the stent-grafts were surgically removed for infection and exteriorization. A femoropopliteal bypass was performed. After 1 year follow-up, the patient is in good clinical condition.

Distal marginal stenosis: a contributing factor in delayed carotid occlusion of a patient with carotid blowout syndrome treated with stent grafts

Distal marginal stenosis is rarely reported to be a factor associated with poor long-term patency of patients of head and neck cancers with carotid blowout syndrome treated with stent grafts. We report a case of laryngeal cancer with rupture of the right common carotid artery. A self-expandable stent graft was deployed, but bleeding recurred. Another stent graft was deployed for the pseudoaneurysm located distal to the first stent graft. Rebleeding occurred because of pseudoaneurysm formation from reconstituted branches of the right superior thyroid artery. We performed direct percutaneous puncture of the proximal superior thyroid artery for successful embolization. Distal marginal stenosis and asymptomatic thrombosis of the carotid artery were noted at 3.5- and 5-month follow-ups, respectively. We suggest aggressive early follow-up and reintervention for distal marginal stenosis by combined antibiotic therapy and angioplasty and stenting to improve the long-term patency of stent-graft deployment for management of carotid blowout syndrome.

Bare metal stent infections: Case report and review of the literature

Infection of bare metal stents in the vasculature is rare, but associated with significant morbidity and mortality. We report two cases of bare metal stent infections and review the literature regarding infected bare metal stents with respect to risk factors, pathophysiology, diagnosis, treatment, and prevention. Overall, this article highlights the need to have a high index of suspicion of bare metal stent infection, since prompt diagnosis and treatment can ultimately decrease the morbidity and mortality associated with this devastating problem.

Endotipsitis: an emerging prosthetic-related infection in patients with portal hypertension

The transjugular intrahepatic portosystemic shunt (TIPS) is an option for the treatment of portal hypertension. However, TIPS infection (endotipsitis) is distinctly uncommon. We report 3 new patients and review 23 published cases of endotipsitis. We calculate an incidence of 1.33% in patients undergoing the procedure. Twenty-three cases (88%) occurred more than a month after the procedure. The most common presentation included fever and primary bacteremia or fungemia. Gram-positive (18 cases), gram-negative microorganisms (10 cases), and fungi (3 cases) were the etiologic agents. Diagnosis may be difficult to establish, and new diagnostic criteria have been proposed. Twenty patients responded well to antibiotic treatment, and the 6 remaining patients died because of the infection. Endotipsitis is a new infectious disease to be considered in patients with a TIPS and bloodstream infection that is not clearly attributable to another source. Prolonged courses of antimicrobial agents can be curative, but liver transplantation is also an option to consider.

Infected endovascular graft secondary to coil embolization of endoleak: a demonstration of the importance of operative sterility

A 60-year-old male underwent endovascular repair of a 5.4-cm enlarging abdominal aortic aneurysm with intraoperative recognition of a type I endoleak. The endoleak was demonstrated to be arising from the left limb of the bifurcated prosthesis. An intravascular stent was placed in the limb near the origin of the common iliac artery and it appeared that the endoleak had sealed. However, 1 month after operation a CT scan demonstrated a persistent, substantial size endoleak without aneurysm enlargement. Coil embolization of the endoleak was undertaken in the interventional radiology suite with apparent satisfactory result. Four days after embolization the patient developed abdominal pain and after 8 days fever and leukocytosis developed. Two weeks after embolization an abdominal CT and indium scan revealed an infected endovascular graft. By CT, the posterior wall of the aneurysm was destroyed and a peri-graft fluid collection with gas was present at the location of the coils. The patient was treated with graft and coil excision and autologous vein reconstruction. Endoluminal prostheses can be contaminated at the time of operative placement. However, an additional source of endoluminal graft infection can arise from secondary endovascular procedures for endoleaks and other graft complications. Since we began placing endovascular grafts at our institution in 1993, most coil embolizations have been performed in the interventional radiology suite. This experience of coil-induced infection causes us to consider performing this type of secondary intervention in the operating room environment.

Infected endovascular stents managed with medical therapy alone

More than 400,000 endovascular stents are put in place in the United States annually. Infectious complications have been reported in fewer than one in 10,000 cases. It remains unclear whether the optimal management strategy for these patients is with medicine alone or surgery. We report two cases of endovascular stent infections that were treated successfully with antibiotics alone.