Mycotic Carotid Artery Pseudoaneurysm Following Stenting

Stent infection and pseudoaneurysm formation after carotid artery stent treated by excision and in situ reconstruction with polytetrafluoroethylene graft: A case report

Background:

Stent infection after carotid artery stenting (CAS) can be a life-threatening postoperative complication, but there is a paucity of data due to its exceedingly low frequency. We report a case of stent infection with pseudoaneurysm formation after CAS that was treated through replacing the infected stent and pseudoaneurysm with a polytetrafluoroethylene (PTFE) synthetic vessel graft.

Case Description:

An 86-year-old man was treated for the right internal carotid artery with CAS in local hospital. One month after stenting, he suffered aspiration pneumonia and septicemia. Three months after stenting, swelling and tenderness of the right side of his neck appeared. His general condition deteriorated due to septicemia and he was unable to ingest anything by mouth as a result of decreasing levels of consciousness. He was transferred to our hospital. Computed tomography and digital subtraction angiography showed the presence of a pseudoaneurysm around the stent. The neck mass enlarged daily and surgical intervention was required to prevent closure of the airway. Stent and pseudoaneurysm resection and in situ reconstruction with a PTFE synthetic vessel graft were performed. The patient returned to his local hospital 36 days after surgery and had a modified Rankin Score of 5.

Conclusion:

Although the risk of reinfection is high due to the nature of artificial material, stent/pseudoaneurysm resection and in situ reconstruction with a PTFE synthetic vessel graft might be one of the best options for patients suffering stent infection after CAS. To the best of our knowledge, this is the first report of treatment using this material.

Stent infection after carotid angioplasty - Treatment with dual layer stent

Stent infection is extremely rare, especially in stents placed in the internal carotid artery (ICA). Treatment in these cases remains controversial and no consensus has been reached, resulting in high mortality in all cases. We report the case of a 78-year-old man undergoing stent placement in the left ICA who, 20 days later, presented with infection at the stent site and a large pseudoaneurysm. The primary infectious focus was the teeth. The patient was treated with antibiotics and placement of a Casper stent, a dual layer braided metal stent with micro-mesh, intended to determine flow diversion and arterial wall reconstruction. Although the procedure was able to reduce the pseudoaneurysm, the patient eventually died of sepsis. We believe that the use of dual layer stents, with a flow-diverting effect, may be a treatment option in selected cases. However, further studies are needed to confirm this hypothesis.

Management of Vascular Infections in Low- and Middle-Income Countries

Background: Vascular infections are rare and challenging conditions with significant deaths and morbidity. Their management necessitates a multi-disciplinary approach and substantial human and financial resources. The management selected may be influenced by the available resources in low- and middle-income countries (LMICs), where such resources may be variable. Methods: We reviewed the published literature and reviewed the management options for various vascular infections with a focus on carotid, aortic, infrainguinal, and dialysis access infections. Results: Recommendations related to prevention and treatment will be offered from the perspective of LMICs. The general principles for prevention are in compliance with established surgical site infection guidelines and minimize the use of prosthetic material. Early detection and intervention by removing all infected prosthetic material, debridement, drainage, and coverage of the infected field with vascularized tissue are essential steps in the management of the infection. Revascularization using an extra-anatomic or in situ approach is individualized based on the resources and expertise available. Conclusions: The prevention and management of vascular infections in LMICs are effective by adhering to time-proven principles even with limited resources.

Post-operative Infection of Prosthetic Materials or Stents Involving the Supra-aortic Trunks: A Comprehensive Review

OBJECTIVE

The aim of this paper was to provide recommendations for diagnosis and management in the setting of infection following open or endovascular reconstructions of the supra-aortic trunks.

METHODS

A review of the Medline database was performed from 1997 to 2017 by a combined strategy of MeSh terms.

RESULTS

The literature search identified 49 publications: 36 studies addressing prosthetic material infections and 13 studies addressing stent infections. A total of 140 cases of prosthetic material infections were reported, mostly involving carotid patches. Surgical treatment was mostly based on complete removal of the infected material followed by in situ arterial reconstruction (86 cases, 62.3%). Peri-operative complications included cranial nerve injury in 17 cases (12.5%), stroke in eight (6.7%), bleeding in four (2.9%), re-infection in five (3.6%), and cardiac failure in three cases (2.2%). Stent infections were reported in 12 patients: eight carotid stents, three subclavian stents and one tandem brachiocephalic subclavian stent. Treatment was not described for one case, was conservative in one case, consisted of stent removal with venous reconstruction in six cases, stent removal without reconstruction because of carotid thrombosis in two cases, and carotid embolisation in two cases. Complications included intra-operative death in one case (9.1%), stroke in two (18.2%), reinfection in one (9.1%), bleeding in one (9.1%), and cardiac failure in one case (9.1%).

CONCLUSION

Appropriate pre-operative imaging is mandatory and treatment modality should be determined by patient condition. Complete removal of the infected material, followed by in situ arterial reconstruction with venous material seems advisable, despite high morbidity. However, alternative strategies may be considered for fragile and high risk patients. A multidisciplinary approach is mandatory to ensure optimum results.

Carotid Artery Pseudoaneurysm after Endovascular Stent Placement: Diagnosis and Follow-up Duplex Ultrasonography

Purpose

Carotid artery pseudoaneurysm development after endarterectomy, albeit rare, has been attributed to patch deterioration. We present an unusual case of pseudoaneurysm development 1 year after stent placement for recurrent carotid artery stenosis.

Case Report

A 64-year-old man had transient hemiparesis develop 1 week after carotid artery endarterectomy (CEA) with patch angioplasty for monocular transient ischemic attack. Carotid angiography reviewed an intimal flap at the distal endarterectomy site, which was successfully treated with carotid stent placement. During a duplex scan 1 year later, he was found to have a symptomatic 2.5-cm pseudoaneurysm at the level of stented carotid bifurcation. This was successfully treated with a combined open and endovascular approach, which consisted of stent-graft placement by means of an open carotid exposure. Completion angiogram showed successful stent-graft exclusion of the pseudoaneurysm. A follow-up duplex scan 6 months later demonstrated diminution of pseudoaneurysm size without endoleak.

Conclusion

This report highlights the importance of duplex ultrasound surveillance in patients with CEA or carotid stenting, because it can accurately detect recurrent stenosis or carotid pseudoaneurysm. Moreover, a combined open and endovascular therapy using stent graft successfully treated the carotid pseudoaneurysm in our patient.

Mycotic Aneurysm of the Internal Carotid Artery Presenting with Multiple Cerebral Septic Emboli

Mycotic aneurysms of the extracranial carotid artery are uncommon and always warrant surgical treatment to prevent eventual rupture and death. Septic embolization to the brain is an even rarer complication of these aneurysms. We present a case of a 79-year-old male with an extracranial internal carotid artery mycotic aneurysm during Staphylococcus aureus bacteremia. He presented with hemiparesis owing to brain embolism from multiple septic emboli originating from the aneurysm. Multidetector computed tomographic angiography contributed to the diagnosis. Resection of the aneurysm and restoration of arterial supply to the brain by vein graft interpositioning was the therapeutic procedure along with long-term antibiotic treatment. A high index of suspicion is required for the diagnosis of a mycotic carotid aneurysm and aggressive treatment is always needed to prevent lethal complications.

Carotid stent infection: a rare but potentially fatal complication of carotid artery stenting

Infections involving endovascular devices are rare and, to our knowledge, only three cases of infection with an inserted carotid stent have ever been reported. A 68-year-old man underwent carotid artery stenting (CAS) of the left proximal internal carotid artery. Two days after CAS the patient developed a high fever and investigation showed that the inserted carotid stent was infected. The infection could not be controlled despite adequate antibiotic therapy. Eventually a rupture of the carotid artery occurred and the patient underwent emergency resection of the left carotid bifurcation in addition to stent removal and reconstruction with a saphenous vein interposition graft. The patient recovered fully without any neurological sequelae.

Carotid stent infection: a rare but potentially fatal complication of carotid artery stenting

Infections involving endovascular devices are rare and, to our knowledge, only three cases of infection with an inserted carotid stent have ever been reported. A 68-year-old man underwent carotid artery stenting (CAS) of the left proximal internal carotid artery. Two days after CAS the patient developed a high fever and investigation showed that the inserted carotid stent was infected. The infection could not be controlled despite adequate antibiotic therapy. Eventually a rupture of the carotid artery occurred and the patient underwent emergency resection of the left carotid bifurcation in addition to stent removal and reconstruction with a saphenous vein interposition graft. The patient recovered fully without any neurological sequelae.

Infections of intravascular bare metal stents: a case report and review of literature

OBJECTIVE

The objective of the paper is to present a case of an infected bare metal stent in the left common iliac artery that was removed by an urgent operation, and to review the literature on diagnosis and outcome of infected coronary and non-coronary metal stents.

METHODS

A systematic search of the Medline database was performed with the purpose of identifying risk factors, signs and symptoms, imaging strategies, and treatment modalities of bare metal stent infections, both coronary and peripheral.

RESULTS

In total, 76 additional studies/case reports (48 non-coronary; 29 coronary) were included and analyzed. Intravascular bare metal stent infections are a rare but serious complication, often leading to emergency surgery (overall: 75.3%; non-coronary cases: 83.3%; coronary cases: 62.1%). In 25.0% of the non-coronary cases, infection led to amputation of an extremity or removal of viscera. Reported mortality was up to 32.5% of the cases (non-coronary: 22.9%; coronary 48.3%). Physicians should always be suspicious of a stent infection when patients present with aspecific symptoms such as fever and chills after stent placement. Additional imaging can be used to detect the presence of a pseudoaneurysm. A PET-CT is an ideal medium for identification of a stent infection.

CONCLUSIONS

Intravascular stent infection is associated with a high risk of morbidity and mortality. Surgery is the preferred treatment option, but not always possible, especially in patients with a coronary stent. In selected cases, bare metal stent infections may be prevented by the use of prophylactic antibiotics at stent placement.

Mycotic pseudoaneurysm of a superficial femoral artery stent

Mycotic pseudoaneurysms are relatively infrequent entities, and the best means of management of them remain to be elucidated due to their small number and medical complexities surrounding them. We present here an interesting case of a mycotic pseudoaneurysm of the superficial femoral artery along with our management of the case and a brief review of the available literature. The particular presentation of this patient will hopefully reinforce the use of prolonged antibiotic therapy for mycotic disease and judicious reexamination of patients whose clinical picture does not immediately fit the framework of our most common diagnoses.

Hemodynamic Regulation of CD34+Cell Localization and Differentiation in Experimental Aneurysms

OBJECTIVES

Bone marrow-derived vascular progenitor cells (CD34+) are present in human and animal models of abdominal aortic aneurysm (AAA) disease. These preterminally differentiated cells may modulate disease resistance. We examined the influence of variable hemodynamic conditions on progenitor cell localization and differentiation in experimental AAAs.

METHODS AND RESULTS

Murine AAAs were created via porcine pancreatic elastase (PPE) infusion. AAA blood flow was increased by aortocaval fistula (ACF) formation (HF-AAA), decreased via left iliac ligation (LF-AAA), or left unchanged (NF-AAA). ACF creation increased flow by 1700%, whereas iliac ligation decreased flow 79% compared with baseline (0.6+/-0.1 mL/min). Wall shear stress (WSS) increased or decreased accordingly, and remained elevated (9.2+/-2.0 dynes/cm2) in HF-AAA 14 days after PPE infusion. CD34+ cells were identified throughout the aortic wall in all flow conditions. Seven days after PPE infusion, HF-AAAs had more CD34+ cells than LF-AAA (187+/-10 versus 155+/-7 CD34+ cells/cross sectional, P<0.05), more medial smooth muscle cells, fewer infiltrative macrophages, and a smaller diameter than LF-AAA. LF-AAAs also contained more adventitial capillaries (CD34+ capillaries 181+/-12 versus 89+/-32/cross-sectional area in HF-AAA, P<0.05). The total progenitor cell/capillary index (CD34+ capillary plus CD31+ capillary/cross sectional area) was higher in LF-AAA (282+/-31 versus 129+/-47, P<0.05). Vascular endothelial (VEGF) and platelet-derived growth factor (PDGF) expression varied directly with capillary density between groups. Increased granulocyte-macrophage colony-stimulating factor (GM-CSF) expression was also present in LF-AAAs.

CONCLUSIONS

Hemodynamic conditions influence CD34+ cell localization and differentiation in experimental AAA. Adventitial capillary angiogenesis may augment inflammation and disease progression. Modulating cell lineage differentiation of mature progenitor cells may represent a novel therapeutic strategy to maintain medial cellularity and extracellular matrix integrity in AAA disease.