Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 97-100

Primary lower-limb arterial stent infection managed with resection and In situ bovine pericardial revascularization


1 Department of Vascular Surgery, Royal Hobart Hospital; Department of Surgery, University of Tasmania, Hobart, Tasmania, Australia
2 Department of Vascular Surgery, Royal Hobart Hospital, Hobart, Tasmania, Australia

Date of Submission13-Oct-2021
Date of Decision05-Nov-2021
Date of Acceptance10-Dec-2021
Date of Web Publication23-Mar-2022

Correspondence Address:
Thomas Lovelock
Department of Vascular Surgery, Royal Hobart Hospital; Department of Surgery, University of Tasmania, Hobart, Tasmania
Australia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_102_21

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  Abstract 


Peripheral arterial stent infection is a rare but morbid condition. We present the case of a patient with primary stent infection of his superficial femoral artery (SFA) and popliteal artery, managed with surgical explant and in situ reconstruction using rifampicin-soaked bovine pericardial tube graft. A 69-year-old man presented with a 3-day history of left groin pain. He had had stents placed into his SFA and popliteal artery in 6 months prior. Duplex ultrasound demonstrated a pseudoaneurysm of the common femoral artery (CFA), with ying-yang flow. A computed tomography angiogram confirmed this pseudoaneurysm, which had a thick rind of nonenhancing soft tissue. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. The patient was taken to the operating theater, and the CFA, profunda femoris artery, and SFA were exposed. After heparinization and clamp control, the pseudoaneurysm was incised, which revealed that the proximal SFA had been completely eroded. All infected tissues were resected. In situ arterial reconstruction was undertaken using a rifampicin-soaked bovine pericardium tube graft. A subsequent positron emission tomography scan revealed high fluorodeoxyglucose uptake around the patients remaining distal SFA and popliteal artery stents. These were explanted in the same manner described above. There is limited evidence regarding the prevention of infection when placing peripheral arterial stents. The Society of Interventional Radiology does not recommend routine prophylactic antibiotics when placing peripheral stents. In situ reconstruction using bovine pericardium is a well-described technique in the management of aortic graft infections, but there is limited experience in its use in a peripheral setting.

Keywords: Bovine pericardium, in situ reconstruction, mycotic aneurysm


How to cite this article:
Lovelock T, Thoo C. Primary lower-limb arterial stent infection managed with resection and In situ bovine pericardial revascularization. Indian J Vasc Endovasc Surg 2022;9:97-100

How to cite this URL:
Lovelock T, Thoo C. Primary lower-limb arterial stent infection managed with resection and In situ bovine pericardial revascularization. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 May 28];9:97-100. Available from: https://www.indjvascsurg.org/text.asp?2022/9/1/97/340491




  Introduction Top


Peripheral arterial stent infection is a rare but morbid condition. Most recommendations for managing this condition are extrapolated from established data on managing infective complications of open arterial surgery. We present the case of a patient who presented to our institution with mycotic aneurysms secondary to infected left superficial femoral artery (SFA) and popliteal artery stents, managed with surgical explant and in situ reconstruction using rifampicin-soaked bovine pericardial tube graft.


  Case Report Top


Informed consent has been obtained from the patient's next of kin for presentation of the case and accompanying images. A 69-year-old man presented to the emergency department with a 3-day history of left groin pain. He had a history of coronary artery bypass grafting, endovascular repair of an abdominal aortic aneurysm, type 2 diabetes mellitus controlled with diet, congestive cardiac failure, Child–Pugh A cirrhosis, and chronic obstructive pulmonary disease (COPD). Six months prior, he had undergone angioplasty and had two uncovered self-expanding stents placed in his SFA and popliteal artery for a nonhealing second toe ulcer. This had failed to improve and 2 months on from this procedure he had another angiographic intervention with angioplasty and a drug-eluting stent placed in his proximal SFA. Both procedures had taken place through percutaneous anterograde common femoral artery (CFA) puncture. He had received prophylactic antibiotics (2 g of intravenous [IV] cephazolin) during the second, but not the first procedure. A StarClose SE closure device (Abbott Medical, Plymouth, USA) was used for hemostasis in the primary procedure, with manual hemostasis in the second. On examination, he had pain on palpation of his groin, with a palpable expansile mass, there were no signs of infection, and the skin was not threatened. A duplex ultrasound was performed, which demonstrated a 22 mm × 18 mm × 26 mm hypoechoic sac with ying-yang flow, in continuation with the CFA, with a 4-mm neck [Figure 1]a. The patient had a leukocytosis, with a white cell count of 14.3 × 106/L, had an acute kidney injury with a creatinine of 116 μmol/L (baseline 64 μmol/L), and was coagulopathic with an International Normalised Ratio (INR) of 2.0. A computed tomography (CT) angiogram was performed which demonstrated the previously described pseudoaneurysm arising from the left CFA, just proximal to the SFA [Figure 1]b. There was a thick rind of nonenhancing soft tissue surrounding it. The patient was commenced on IV piperacillin/tazobactam and vancomycin. His coagulopathy was corrected with Vitamin K and fresh frozen plasma. Lower-limb vein mapping ultrasound revealed that the left greater saphenous vein was thrombosed, with the right greater saphenous vein having previously been used in coronary artery bypass grafting.
Figure 1: Arterial duplex ultrasound and computed tomography angiogram demonstrating proximal superficial femoral artery pseudoaneurysm from primary stent infection. An arterial duplex was performed on the patient, which demonstrated a 22 mm × 18 mm × 26 mm hypoechoic sac with ying-yang flow, suggestive of a proximal SFA pseudoaneurysm (a). Computed tomography angiography was performed which confirmed the pseudoaneurysm and revealed a surrounding thick rind of nonenhancing tissue (b)

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The following day, the patient was taken to the operating theater and the proximal left CFA was exposed. The left SFA was exposed distal to the site of the pseudoaneurysm, which overlaid the distal CFA and profunda femoris origin. 2500 IU of IV heparin was administered. The SFA and proximal CFA were clamped, and the pseudoaneurysm sac was incised. The arterial wall had completely disintegrated, and the proximal SFA stent was on view. There was purulent material within the pseudoaneurysm sac. Tissue and swabs were sent for microscopy. The infected artery was resected. As there were concerns regarding the viability of the patient's leg if the SFA was to be ligated, in situ arterial reconstruction was performed using a bovine pericardial patch. A GIA Vascular Stapler (Medtronic, Minneapolis, USA) was used to fashion this into a tube, and the graft was soaked in rifampicin before being used as an interposition bypass. Proximal and distal anastomoses were completed with 6/0 Prolene.

Blood cultures from admission grew methicillin-sensitive Staphylococcus aureus, and the patient was switched to IV flucloxacillin. A transthoracic echocardiogram was performed which did not display any evidence of infective endocarditis. Concerns regarding the patient's endovascular aneurysm repair (EVAR) prompted a positron emission tomography (PET)/CT scan to be undertaken, which did not display any evidence of EVAR infection, but did display high fluorodeoxyglucose uptake surrounding the patient's left popliteal artery stent [Figure 2]. Despite appropriate antibiotic therapy, the patient had ongoing positive blood cultures 5 days following the initial excision of the mycotic aneurysm and so the decision was made to explant the remaining popliteal artery stent. A medial lower thigh incision was made, and the above-knee popliteal artery was exposed. There was a pseudoaneurysm of the distal SFA [Figure 3]a. 2500 IU of IV heparin was administered. The artery was controlled with vascular loops proximal and distal to the pseudoaneurysm, and the pseudoaneurysm was excised. The distal SFA and popliteal stents were both removed. In situ arterial reconstruction of the resected artery was performed in the manner described previously [Figure 3]b.
Figure 2: Positron emission tomography scan demonstrating infection of the remaining distal superficial femoral artery and popliteal artery stents. A positron emission tomography scan was performed to investigate the possibility of infection of the patient's endovascular aneurysm repair. This demonstrated no evidence of infection of the endovascular aneurysm repair, however, there was increased uptake of fluorodeoxyglucose at the site of the distal superficial femoral artery and popliteal artery stents (a and b), concerning for infection

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Figure 3: Pseudoaneurysm of the distal superficial femoral artery and in situ reconstruction using a bovine pericardial tube graft. A medial lower thigh incision was made. The distal superficial femoral artery was exposed, and the pseudoaneurysm was dissected out (a). Proximal and distal control was obtained. The patient was systemically heparinized with 2500 IU of heparin, and an interposition bypass was performed using a tube graft of bovine pericardium, fashioned using a GIA Vascular Stapler (b) (Medtronic, Minnea)

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The patient progressed well postoperatively and was on the ward 10 days following the second operation when he suffered an episode of melena, associated with an acute drop in his hemoglobin from 91 g/dl to 52 g/dl. He was resuscitated with blood products and his coagulopathy corrected. An esomeprazole infusion was commenced, and the patient referred to gastroenterology. A gastroscopy was performed which demonstrated superficial ulcers of the distal esophagus and proximal duodenum, as well as an actively bleeding gastric ulcer with overlying clot. This was treated with adrenaline injection, electrocautery, and hemostatic agents. Despite successful treatment of his gastrointestinal hemorrhage, the patient developed worsening fluid overload, acute kidney injury, and Klebsiella pneumoniae bacteremia presumed secondary to pneumonia. After discussion with the patient and his family regarding his goals of care, the patient was transitioned to palliative management, and died 10 days after his gastroscopy.


  Discussion Top


Infection of peripheral arterial stents is a rare phenomenon. A 2014 literature review found only 48 reported cases of noncoronary bare metal stent infections reported in the literature.[1] Despite this, peripheral arterial stent infection is a serious complication, with mortality rates exceeding 20% and major amputation rates of 25%.[1] While infection rates following endovascular surgery appear to be lower than in open arterial surgery, in vivo studies have suggested greater pathogenicity of endovascular graft infections, with higher colony counts observed in endovascular grafts inoculated with S. aureus in dogs, compared with standard polytetrafluoroethylene grafts.[2],[3] Similarly, endovascular grafts appeared to rupture at lower colony counts when compared to their open counterparts.[2] Peripheral stent infection may be split into early (<4 weeks) and late (>4 weeks) infection, with differing organisms responsible for each.[4] The use of drug-coated devices with antiproliferative agents may increase the risk of stent infection. Since 2003, two-thirds of reported cases of infected coronary stents were in drug-eluting devices. The mechanism by which this occurs is incompletely elucidated but may involve reduced neointima formation, allowing for easier bacterial penetration into the arterial wall.[5]

Failure to administer prophylactic antibiotics before peripheral arterial stenting has not been established as a risk factor for peripheral arterial stent infection.[1],[4] The Society of Interventional Radiology (SIR) is the only guideline which has been published regarding antibiotic prophylaxis prior to peripheral arterial stenting.[6] These do not recommend prophylactic antibiotics for routine stent placement, and suggest considering IV cephazolin prophylaxis for high-risk patients, such as those who are having a prolonged indwelling arterial sheath for >24 h, a repeat intervention within 7 days, or a prolonged duration of procedure. Stent grafts are thought to convey a higher risk of infection, and so prophylactic IV cephazolin is recommended routinely prior to placement.[6] Our patient received prophylactic IV antibiotics prior to their second procedure, but not the first. While the patient did not meet the criteria for prophylactic antibiotics as per the SIR guidelines, he did have several high-risk comorbidities such as a previous EVAR, diabetes mellitus, COPD, and chronic liver disease that may have prompted consideration of antibiotic prophylaxis. It is possible that the closure device used in the patient's initial procedure acted as a nidus of infection, given the location of the proximal pseudoaneurysm. The use of closure devices in prior procedures may be another factor requiring consideration when deciding about antibiotic prophylaxis in secondary peripheral arterial interventions.

Several imaging modalities exist which may aid in the diagnosis of vascular graft infection. Ultrasonography, CT angiography, or magnetic resonance imaging may prove useful primary investigations. However, CTA alone may have high false-negative rates, particularly in low-grade infection.[7] Nuclear medicine scanning may permit the identification of infection or inflammation by demonstrating molecular uptake of radionucleotide tracers before morphological changes are evident.[7] FDG-18 PET/CT fuses this with CT imaging to provide more accurate localization of inflammatory changes. In our setting, a PET/CT scan was undertaken to rule out infection of the patient's EVAR, which revealed infection of the distal SFA stent. This pathology was not evident on the patient's admission CT angiogram. In retrospect, delaying the initial surgical debridement to allow an initial PET/CT scan may have altered our initial surgical approach and provided valuable prognostication information.

Several strategies exist for the treatment of the infected arterial field. The mainstay of treatment involves radical debridement of the infected field, with or without arterial reconstruction, which may either be in situ or extra-anatomical. In our setting, given concerns about the adequacy of arterial supply to the patient's leg, we opted to perform arterial reconstruction. Silver-coated or rifampicin-soaked grafts are options for conduit in this setting but have greater rates of reinfection when compared to autologous options.[8] In this setting, there was no autologous vein readily available given the patient's previous history of long saphenous vein harvest for coronary artery bypass grafting. As such, we opted for the use of bovine pericardium. Extra-anatomical bypass is often preferred as it avoids leaving a graft in an infected field, however, this would have necessitated further extensive dissection in a medically comorbid patient to gain appropriate proximal and distal control distant to the site of infection, as well as the implantation of a prosthetic graft, and so was decided against in this setting. The use of bovine pericardium is well described in in situ reconstruction following aortic graft infection, where it may be fashioned into a tube graft with either a vascular stapler or suture.[8] There have also been promising reports of bovine pericardial patch repair in the explant of infected vascular grafts, with low rates of recurrent infection.[9] Our use of bovine pericardium tube graft as an infrainguinal interposition bypass is less described. Unfortunately, as the patient died following postoperative gastrointestinal hemorrhage, we are unable to comment on the long-term patency or reinfection rates. However, we offer this technique as a described option for the vascular surgeon dealing with an infrainguinal infected arterial field requiring revascularization, with no autologous conduit available.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bosman WM, Borger van der Burg BL, Schuttevaer HM, Thoma S, Hedeman Joosten PP. Infections of intravascular bare metal stents: A case report and review of literature. Eur J Vasc Endovasc Surg 2014;47:87-99.  Back to cited text no. 1
    
2.
Parsons RE, Sanchez LA, Marin ML, Holbrook KA, Faries PL, Suggs WD, et al. Comparison of endovascular and conventional vascular prostheses in an experimental infection model. J Vasc Surg 1996;24:920-5.  Back to cited text no. 2
    
3.
Fiorani P, Speziale F, Calisti A, Misuraca M, Zaccagnini D, Rizzo L, et al. Endovascular graft infection: Preliminary results of an international enquiry. J Endovasc Ther 2003;10:919-27.  Back to cited text no. 3
    
4.
Greaves NS, Katsogridakis E, Faris B, Murray D. Prophylactic antibiotics for percutaneous endovascular procedures. Eur J Clin Microbiol Infect Dis 2017;36:597-601.  Back to cited text no. 4
    
5.
Sangolkar R, Ketana VR, Sastry BK. Coronary artery stent infection presenting as coronary cameral fistula: A case report. Eur Heart J Case Rep 2018;2:yty067.  Back to cited text no. 5
    
6.
Venkatesan AM, Kundu S, Sacks D, Wallace MJ, Wojak JC, Rose SC, et al. Practice guidelines for adult antibiotic prophylaxis during vascular and interventional radiology procedures. Written by the standards of practice Committee for the Society of Interventional Radiology and Endorsed by the Cardiovascular Interventional Radiological Society of Europe and Canadian Interventional Radiology Association [corrected]. J Vasc Interv Radiol 2010;21:1611-30.  Back to cited text no. 6
    
7.
Lauri C, Iezzi R, Rossi M, Tinelli G, Sica S, Signore A, et al. Imaging modalities for the diagnosis of vascular graft infections: A consensus paper amongst different specialists. J Clin Med 2020;9:1510.  Back to cited text no. 7
    
8.
Almási-Sperling V, Heger D, Meyer A, Lang W, Rother U. Treatment of aortic and peripheral prosthetic graft infections with bovine pericardium. J Vasc Surg 2020;71:592-8.  Back to cited text no. 8
    
9.
McMillan WD, Leville CD, Hile CN. Bovine pericardial patch repair in infected fields. J Vasc Surg 2012;55:1712-5.  Back to cited text no. 9
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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