Osteomyelitis of the spine and abscess formation in the left thigh after stent-graft implantation in the superficial femoral artery

Superficial femoral artery stent extrusion

The superficial femoral artery is a common location for endovascular treatment of occlusive arterial disease. Stent extrusion is an uncommon complication of stent placement. In the present case report, we sought to raise awareness of this rare complication and have described the management of a single unique case. Although rare, the complication of stent extrusion should be considered in patients with abnormal symptoms after endovascular treatment of superficial femoral artery disease.

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.

Management of a large ruptured popliteal artery aneurysm involving combined deployment of a covered stent graft and evacuation of popliteal fossa hematoma

Popliteal artery aneurysms (PAAs) are the most common of all peripheral aneurysms. However, ruptured PAA is rare, accounting for approximately 2% of PAA presentations. A literature review found only 11 published cases of ruptured PAAs treated with endovascular repair. In this case, a large (6.9 cm in diameter) ruptured PAA was successfully treated with endovascular repair using the GORE VIABAHN (W. L. Gore & Associates, Flagstaff, Ariz) stent graft and had simultaneous evacuation of popliteal fossa hematoma through a medial distal thigh incision. This facilitated more rapid recovery of mobility, reduced pain, and reduced hospital stay and may represent a useful hybrid surgical approach for this rare condition.

Acute infection of Viabahn stent graft in the popliteal artery

Peripheral stents are increasingly used for treatment of peripheral arterial disease, yet all implanted devices are potentially at risk for infection. We describe a 51-year-old man who underwent stenting in the femoropopliteal artery and presented 3 days later with leg pain, fever, and evidence of peripheral stigmata of embolization. Blood cultures grew methicillin-resistant Staphylococcus aureus and remained persistently positive despite antibiotic therapy. At surgical exploration, the popliteal artery had essentially been disintegrated by the infection, with only visible stent graft maintaining arterial continuity. Acute stent graft infections are rare and must be managed promptly to reduce morbidity.

An Update on Endovascular Therapy of the Lower Extremities

Considerable advances have been made over the last decade in percutaneous technology for treatment of atherosclerotic diseases in the iliac, femoropopliteal, and distal tibioperoneal arteries. While treatment strategies are well defined in the iliofemoral segment, where angioplasty and stenting perform well in appropriately selected lesions, the search for a durable transcatheter therapy for femoropopliteal and distal occlusive disease continues. The spectrum of treatment alternatives to angioplasty ranges from transcatheter plaque excision to laser ablation, rotational atherectomy, cryoplasty, brachytherapy, and stenting. We review in this article the status of percutaneous endovascular techniques for the treatment of lower extremity vascular occlusive disease.

Current state of endovascular treatment of femoro-popliteal artery disease

Considerable advances have been made over the last decade in percutaneous technology for the treatment of atherosclerotic diseases in the femoro-popliteal arteries. While treatment strategies are well defined in the iliac segment, where angioplasty and stenting perform well in appropriately selected lesions, the search for a durable transcatheter therapy for femoro-popliteal lesions continues. Whereas balloon angioplasty (PTA) is the accepted therapy for short lesions, long diffuse lesions are still recommended for surgical treatment. However, attractive new technologies ranging from transcatheter plaque excision to laser ablation, rotational atherectomy, cryoplasty, brachytherapy, and placement of drug-eluting stents to simple angioplasty with drug-coated balloons may have the potential to replace femoro-popliteal bypass surgery as a treatment of choice for complex lesions. This article reviews the status of percutaneous endovascular techniques for the treatment of femoro-popliteal artery occlusive disease.

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.

An update on endovascular therapy of the lower extremities

Considerable advances have been made over the last decade in percutaneous technology for treatment of atherosclerotic diseases in the iliac, femoropopliteal, and distal tibioperoneal arteries. While treatment strategies are well defined in the iliofemoral segment, where angioplasty and stenting perform well in appropriately selected lesions, the search for a durable transcatheter therapy for femoropopliteal and distal occlusive disease continues. The spectrum of treatment alternatives to angioplasty ranges from transcatheter plaque excision to laser ablation, rotational atherectomy, cryoplasty, brachytherapy, and stenting. We review in this article the status of percutaneous endovascular techniques for the treatment of lower extremity vascular occlusive disease.

Sternal osteomyelitis complicating percutaneous coronary artery stenting

Hematogenous sternal osteomyelitis is a rare infection that has been associated with i.v drug abuse and blunt thoracic trauma, but iatrogenic infections have also been described following resuscitation and in conjunction with hemodialysis catheters. Staphylococcus aureus is the most common causative organism. Stenting is the preferred treatment for isolated stenosis of the coronary artery and is associated with a low complication rate and high patency rate. Such intravascular procedures are rarely complicated by infections. A 72-year-old man developed hematogenous sternal osteomyelitis following coronary artery stenting. Radiological diagnosis was made using CT scan and MRI, and blood cultures and aspiration fluid from the infected soft tissue were positive for S. aureus. Initial therapy consisted of i.v. second-generation cephalosporin followed by oral cephalexin and later linezolid. Prolonged antibiotic therapy without surgical intervention was successful in controlling this rare complication. The patient was well at the one-year follow up, with patent stent and no signs for recurrent osteomyelitis. Although transcutaneous stenting is a widely accepted strategy for treating stenosed arteries, this case highlights the possibility of hazardous infectious complications associated with such procedures.

Aneurysmal Degeneration of the Superficial Femoral Artery following Stenting: An Uncommon Infectious Complication

Infrainguinal angioplasty and stenting is becoming a more commonly performed procedure. Its durability remains a matter of debate, however. Aneurysmal degeneration following angioplasty and stenting is a complication not previously described in the literature with regard to the superficial femoral artery. We present a case in which two aneurysms of the superficial femoral artery developed following angioplasty and multiple-stent placements in a patient who had previously undergone a failed femoral-to-below-the-knee popliteal artery PTFE bypass graft. The patient presented to our institution with an occluded, infected bypass graft. He was treated with graft and femoral artery/stent excision and vein bypass grafting. A brief review of infectious complications after stent placement is included.

Endovascular treatment and complete regression of an infected abdominal aortic aneurysm

PURPOSE

To report a case of successful endovascular treatment of an infected abdominal aortic aneurysm (AAA) following Salmonella septicemia.

CASE REPORT

A 60-year-old man was admitted for rapid onset of urinary frequency, fever, and suprapubic pain extending to the flanks. Blood cultures were positive for Salmonella enteritidis, and appropriate antibiotic treatment was started. After 4 weeks, fever ceased and the C-reactive protein fell to 5.8 mg/dL, but the erythrocyte sedimentation rate remained unchanged. Back pain prompted computed tomography, which showed a large AAA with a very irregular aortic wall suspicious of impending rupture. A tube stent-graft was introduced under general anesthesia from a left groin incision and deployed immediately below the renal arteries; a proximal type I endoleak was suspected but not repaired. Oral antibiotic therapy was continued for 2 months after discharge. By 6 months, the endoleak had sealed with a concomitant decrease in the maximal diameter of the aneurysm from 7.4 to 5.6 cm. At 4 years, the aneurysm sac was no longer visible.

CONCLUSIONS

Although experience is limited, endovascular grafting in combination with antibiotic therapy in selected infected aneurysms might represent an effective low-risk alternative to conventional surgery with the potential to restore normal vascular anatomy.

Waligraft endoprosthesis for the percutaneous treatment of femoral and popliteal artery aneurysms

PURPOSE

To evaluate the safety and efficacy of the Wallgraft Endoprosthesis for the treatment of femoropopliteal artery aneurysms.

METHODS

From October 1997 to April 2000, 17 patients (13 men; mean age 73.5 +/- 7.1 years) with 7 femoral and 13 popliteal artery aneurysms underwent percutaneous aneurysm exclusion using the Wallgraft Endoprosthesis as part of a larger clinical trial. The mean aneurysm diameters were 37.6 +/- 12.9 mm and 22.3 +/- 8.7 mm, respectively.

RESULTS

Acute procedural success was 100% for femoral aneurysms and 92.3% (12/13) in the popliteal artery owing to one endoleak that resolved after 1 month. There were no complications, and the mean length of stay was 2.2 +/- 3.8 days. Six-month and 1-year aneurysm exclusion rates were 100% for both locations, but 4 (31%) popliteal stent-grafts thrombosed in follow-up. Three were recanalized, but the fourth underwent bypass grafting after 3 thrombotic episodes. The 1-year primary and secondary patency rates were both 100% for the femoral aneurysms and 69% and 92%, respectively, for popliteal repairs. No procedure or device-related deaths occurred.

CONCLUSIONS

Treatment of aneurysms in the femoropopliteal segment appears to be safe and effective with the Wallgraft Endoprosthesis, although longer follow-up in a larger patient group will be needed to determine this technique's potential versus surgical repair.

"Accordion" deformity of a tortuous external iliac artery after stent-graft placement

PURPOSE

To identify a complication of endograft deployment in aneurysmal iliac arteries.

CASE REPORT

A 71-year-old man was referred for endovascular treatment of a 60-mm-diameter right common iliac artery aneurysm; however, deployment of a homemade covered stent (Palmaz-Schatz and polytetrafluoroethylene) induced shortening of the tortuous external iliac artery, causing an "accordion" deformity. The anomaly proved difficult to treat with serial Wallstent deployment, because the convolution tightened and migrated caudally with each stent deployed, threatening outflow. Finally, after 3 Wallstents were implanted, the contour of the external iliac artery was straight, and flow was unimpeded. However, 3 weeks later, the external iliac artery had recoiled to its original redundant appearance, but flow remained satisfactory. The aneurysm remains excluded, with satisfactory distal flow after 24 months.

CONCLUSIONS

Implanting endografts in redundant, tortuous arterial segments may prove problematic, since induced straightening by the device precipitates kinking in the redundant system. Although treatment may be required in some situations, the vessels may return to a noncompressed state by removing the delivery system and guidewire.

Endovascular repair of an aortoduodenal fistula

PURPOSE

To demonstrate the utility of endovascular stent-graft repair for the management of an unusual aortoduodenal fistula.

METHODS AND RESULTS

A 23-year-old man with an aortoduodenal fistula secondary to tumor necrosis was treated with a Corvita endoluminal stent-graft after several failed surgical attempts to repair the defect. At 2-year follow-up, the patient was clinically and radiographically devoid of any evidence of occult stent-graft infection.

CONCLUSIONS

This case illustrates the usefulness of endovascular repair for the treatment of a primary aortoduodenal fistula. Endovascular repair should be included in the armamentarium for the management of difficult aortoduodenal fistulas.

Stent-graft treatment for bleeding from a presumed aortoenteric fistula

PURPOSE

To describe a technique for the endovascular treatment of aortoenteric fistula.

METHODS AND RESULTS

A 67-year-old man who had undergone aortobi-iliac grafting for aneurysmal disease 8 years previously presented with life-threatening upper gastrointestinal hemorrhage. Endoscopy after resuscitation did not identify the source of the bleeding. Computed tomographic (CT) scanning and angiography revealed pseudoaneurysm formation at the upper anastomosis 1 cm below the renal arteries. Measurements were taken for endovascular repair. Uncomplicated emergency aortic endografting for exclusion of the pseudoaneurysm was performed using a 28-mm x 3.75-cm AneuRx device. Gastrointestinal hemorrhage ceased. CT scanning at 6 months confirmed the absence of a pseudoaneurysm, and the patient remains symptom free at 18 months.

CONCLUSIONS

Endovascular treatment of aortoenteric fistula may represent a technique for treating gastrointestinal hemorrhage and for lessening the morbidity and mortality of open repair.