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Aortobifemoral perigraft abscess: Treatment by percutaneous catheter drainage
Aortobifemoral perigraft abscess: Treatment by percutaneous catheter drainage K a t h e r i n e D. T o b i n , M D , Baltimore, M d . There is significant morbidity and mortality associated with infected prosthetic aortic grafts. The preferred method of treatment is excision of the involved graft and revascularization. Percutaneous catheter drainage o f abscesses under CT scanning or ultrasound guidance has been shown to be an effective alternative to surgery. This is a case of a patient with a retroperitoneal abscess involving the femoral limb of an aortobffemoral bypass graft, which was successfiflly treated by percutaneous catheter drainage. In selected high-risk patients this may be a safe alternative to surgical therapy. (J VASC SoRG 1988;8:339-43.)
Infection o f abdominal vascular prosthetic grafts is one o f the most difficult problems encountered in vascular reconstructive surgery. Although the incidence o f infection is low, it is associated with a high mortality rate and significant morbidity from limb loss. 1-4 CT scanning, in conjunction with fine needle aspiration, has been shown to be a rapid, sensitive method for diagnosing infected perigraft collections, s9 Traditional treatment o f infected prostheses has been removal o f the involved graft and early or late revascularization. 1-a'~° This article reports a case o f an infected perigraft abscess successfully treated by percutaneous catheter drainage.
CASE REPORT A 64-year-old white man had an uncomplicated aortobifemoral bypass with a knitted Dacron graft via a left rettoperitoneal approach to treat aortoiliac occlusive disease on Feb. 20, 1987. No postoperative complications occurred and he was discharged 6 days later. A subcutaneous seroma developed in the left flank incision, which was opened at home and left to heal by second intention. On March 23, 1987, he came for treatment complaining of fever and chills of 2 days' duration. Pertinent admission findings were a temperature of 102° F, white blood cell count of 22,400/mmS; the left flank and groin incisions were clean, the abdomen was nontender, and femoral pulses were + 2 bilaterally. A CT scan of the abdomen and pelvis the day after admission showed an inhomogeneous collection in the right retroperitoneum, which surrounded the right limb of the bypass graft (Fig. 1). The proximal From the Department of Diagnostic Radiology, University of Maryland Medical System/Hospital and Loch Raven Veterans Administration Hospital. Reprint requests: K. D. Tobin, MD, Dept. of Radiology, Universityof MarylandMedicalSystem/Hospital,22 South Greene St., Baltimore, MD 21201.
and distal anastomotic sites did not appear to be involved. No gas bubbles were identified in the collection. A second subcutaneous collection was noted in the region of the left flank incision. Real-time ultrasound of the pelvic collection showed that the right limb of the bypass graft extended through the complex collection (Fig. 2). The CT and ultrasound findings were consistent with either a sterile or infected hematoma. Incision and drainage of the left flank process yielded pus; brick-colored fluid was aspirated from the retroperitoneal collection under CT guidance. Blood, urine, and aspirate cultures grew methicillin-resistant Staphylococcus aureus. The patient was given intravenous vancomycin, 1 gm, every 12 hours. After 24 hours the vancomycin was discontinued and the regimen was changed to intravenous nafcillin, 1.5 gm, every 4 hours. Culture sensitivities showed that the new drug would be effective. After treatment with antibiotics the patient became afebrile; however, the white blood cell count remained elevated (16,000 to 20,000/mm 3) and the patient began complaining of decreased range of motion of the right hip and abdominal pain. A repeat CT scan obtained 7 days after admission revealed an increase in the size of the retroperitoneal abscess with enlargement and inhomogeneity of the right iliopsoas muscle consistent with inflammatory involvement (Fig. 3). At that time an 8.5F Sachs pigtail catheter with multiple side holes was percutaneously placed in the abscess under real-time ultrasound guidance (Fig. 4). Sixty cubic millimeters of purulent, brick-colored material was aspirated. After percutaneous drainage the patient showed marked clinical improvement. Over 4 weeks he remained afebrile, the white blood cell count returned to normal, and the right hip and abdominal pain resolved. The drain was removed 41 days after placement and the patient was discharged 4 days later with a regimen of oral dicloxacillin. A follow-up CT scan obtained 7 months later showed no evidence of a residual abscess (Fig. 5). An aortogram performed at that time demonstrated an intact graft. The pa339
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Tobin
Fig. 1. CT scan of the abdomen and pelvis with oral and intravenous contrast material. There is an inhomogeneous low density collection in the right peMs, which deviates the right ureter anteriorly (open arrowhead). The right limb of the prosthesis is in the center of the lesion (black
arrowhead).
Fig. 2. Real-time ultrasound of the right pelvis shows the vascular graft (arrows) stlrrounded by a hypoechoic complex collection.
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Fig. 3. CT scan 7 days after admission shows an increase in the size of the abscess with inflammatory involvement of the right iliopsoas muscle (arrowheads).
tient is to continue taking oral dicloxycillin,250 mg three times a day, for life. DISCUSSION There have been reports of the successful management of infected grafts by local debridement and antibiotic or povidone-iodine irrigation, u~4 However, this method of treatment is not generally accepted and preferred treatment consists of excision of the infected prosthesis and revascularization. 14 The associated morbidity and mortality rates are high because these patients are debilitated by complications of the infection and other coexisting disorders, such as cardiac or renal dysfunction.3 Graft infections may be classified as perigraft infections, anastomotic-enteric fistula, or nonanastomotic-enteric erosions.2'3 Abscesses in anatomic continuity with a graft can lead to subsequent perigraft infections? The patient reported in this case had a localized collection surrounding the tight limb of an aortobifemoral graft, which, according to findings of CT scanning, ultrasound, and fine needle aspiration, was consistent with a postsurgical hematoma. This collection presumably became infected by hematogenous seeding from the left flank wound infection.
This case illustrates the successful conservative management of a perigraft abscess by percutaneous catheter drainage. The patient was a poor candidate for surgery at the time of presentation because of sepsis, concurrent retroperitoneal and flank abscesses, and a history of severe coronary and peripheral atherosclerotic disease. By clinical evaluation of the groin incisions, and by CT and ultrasound criteria, the proximal and distal anastomotic sites did not appear to be involved. The graft was considered patent by Doppler studies and physical examination. Because there was no evidence of immediate threat of limb ischemia from graft thrombosis, this patient was considered a candidate for a trial of conservative therapy by percutaneous drainage. CT- or ultrasound-guided percutaneous catheter drainage has been shown to be an effective alternative to surgery in the treatment of intraabdominal or retroperitoneal abscesses, ls-17 However, this is the first reported case of percutaneous drainage of an abscess involving a vascular prosthesis. The patient showed marked clinical improvement immediately after drainage and the prosthesis was saved with no evidence of occlusion, pseudoaneurysm formation, anastomotic breakdown, or development of enteric fistulas.
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Fig. 4. CT scan after percutaneous catheter placement verifies the catheter position within the abscess (arrowheads).
Fig. 5. CT scan performed 7 months later shows no cvidence of residual abscess.
Tim definitive treatment o f infected aortic prosthetic grafts in most cases remains surgical excision. However, this case illustrates that in selected highrisk patients with patent grafts and localized perigraft
infections, conservative treatment by percutaneous catheter drainage may be effective either as definitive treatment or as a temporizing measure before surgery. If the antibiotics have not already been
Volume 8 Number 3 September 1988
started or if the results of blood, urine, or wound cultures are pending, broad-spectrum antibiotics should be given before and after percutaneous drainage. Many different organisms may be responsible for graft infections1,2; adequate antibiotic coverage is necessary until a specific organism is identified and to prevent the complications of bacteremia and septicemia during catheter manipulation, isit A diagnostic needle aspiration for immediate Gram's stain and culture should always be performed before catheter insertion. The choice of appropriate long-term antibiotic coverage should be made on thc basis of the cultures and sensitivity studies of the aspirate. REFERENCES
1. O'Hara PJ, Hertzer NR, Beven EG, Krajewski LP. Surgical management of infected abdominal aortic grafts: review of a 25-year experience. I VASe SUr,G 1986;3:725-31. 2. Talkington CM, Thompson JE. Prevention and management of infected prostheses. Surg Clin North Am 1982;62:51530. 3. Goldstone J. The infected infra-renal aortic graft. Acta Chir Scand 1987;538:72-86. 4. Turnipseed WD, BerkoffHA, Detmer DE, Acher CW, Belzer FO. Arterial graft infections. Delayed vs immediate vascular reconstruction. Arch Surg 1983;118:410-4. 5. Hilton S, Megibow AJ, Naidich DP, Bosniak MA. Computed tomography of the postoperative abdominal aorta. Radiology 1982;145:403-7. 6. Mark A, Moss AA, Lusby R, Kaiser IA. CT evaluation of complications of abdominal aortic surgery. Radiology 1982; 145:409-14.
Percutaneous drainage of perigraft abscess 343
7. Mark AS, McCarthy SM, Moss AA, Price D. Detection of abdominal aortic graft infection: comparison of CT and Inlabeled white blood cell scans. AJR 1985;144:315-8. 8. Cunat JS, Haaga RJ, Rhodes R, Bekeny J, Yousef SE. Periaortic fluid aspiration for recognition of infected graft: preliminary report. AJR 1982;139:251-3. 9. Katz BH, Black RA, Colley DP. CT-guided fine needle aspiration of a pcriaortic collection. J VASC SURG 1987;5: 762-4. 10. Bernhard VM. Management of graft infections following abdominal aortic aneurysm replacement. World J Surg 1980; 4:679-88. 11. Szilagyi DE, Smith RF, Elliott JP, Vrandecic MP. Infection in arterial reconstruction with synthetic grafts. Ann Surg 1972;176:321-32. 12. Liekweg WG Jr, Greenfield LJ. Vascular prosthetic infections: collected experience and results of treatment. Surgery 1977; 81:335-42. 13. Kwaan JHM, Connolly JE. Successful management of prosthetic graft infection with continuous povidone-iodine irrigation. Arch Surg 1981;116:716-9. 14. Knight CD, Farnell MB, Hollier LH. Treatment of aortic graft infection with povidone-iodine irrigation. Mayo Clin Proc 1983;58:472-5. 15. Gerzof SG, Robbins AH, Birkett DH, Johnson WC, Pugatch R,D, Vincent ME. Percutaneous catheter drainage of abdominal abscesses guided by ultrasound and computed tomography. AIR 1979;133:1-8. 16. van Sormenberg E, Mueller PR, Ferrucci JT. Percntaneous drainage of 250 abdominal abscesses and fluid collections. Radiology 1984;151:337-41. 17. Mueller PK, van Sonnenberg E, Ferrucci JT. Percutaneous drainage of 250 abdominal abscesses and fluid collections. Radiology 1984;151:343-7.
Infection o f abdominal vascular prosthetic grafts is one o f the most difficult problems encountered in vascular reconstructive surgery. Although the incidence o f infection is low, it is associated with a high mortality rate and significant morbidity from limb loss. 1-4 CT scanning, in conjunction with fine needle aspiration, has been shown to be a rapid, sensitive method for diagnosing infected perigraft collections, s9 Traditional treatment o f infected prostheses has been removal o f the involved graft and early or late revascularization. 1-a'~° This article reports a case o f an infected perigraft abscess successfully treated by percutaneous catheter drainage.
CASE REPORT A 64-year-old white man had an uncomplicated aortobifemoral bypass with a knitted Dacron graft via a left rettoperitoneal approach to treat aortoiliac occlusive disease on Feb. 20, 1987. No postoperative complications occurred and he was discharged 6 days later. A subcutaneous seroma developed in the left flank incision, which was opened at home and left to heal by second intention. On March 23, 1987, he came for treatment complaining of fever and chills of 2 days' duration. Pertinent admission findings were a temperature of 102° F, white blood cell count of 22,400/mmS; the left flank and groin incisions were clean, the abdomen was nontender, and femoral pulses were + 2 bilaterally. A CT scan of the abdomen and pelvis the day after admission showed an inhomogeneous collection in the right retroperitoneum, which surrounded the right limb of the bypass graft (Fig. 1). The proximal From the Department of Diagnostic Radiology, University of Maryland Medical System/Hospital and Loch Raven Veterans Administration Hospital. Reprint requests: K. D. Tobin, MD, Dept. of Radiology, Universityof MarylandMedicalSystem/Hospital,22 South Greene St., Baltimore, MD 21201.
and distal anastomotic sites did not appear to be involved. No gas bubbles were identified in the collection. A second subcutaneous collection was noted in the region of the left flank incision. Real-time ultrasound of the pelvic collection showed that the right limb of the bypass graft extended through the complex collection (Fig. 2). The CT and ultrasound findings were consistent with either a sterile or infected hematoma. Incision and drainage of the left flank process yielded pus; brick-colored fluid was aspirated from the retroperitoneal collection under CT guidance. Blood, urine, and aspirate cultures grew methicillin-resistant Staphylococcus aureus. The patient was given intravenous vancomycin, 1 gm, every 12 hours. After 24 hours the vancomycin was discontinued and the regimen was changed to intravenous nafcillin, 1.5 gm, every 4 hours. Culture sensitivities showed that the new drug would be effective. After treatment with antibiotics the patient became afebrile; however, the white blood cell count remained elevated (16,000 to 20,000/mm 3) and the patient began complaining of decreased range of motion of the right hip and abdominal pain. A repeat CT scan obtained 7 days after admission revealed an increase in the size of the retroperitoneal abscess with enlargement and inhomogeneity of the right iliopsoas muscle consistent with inflammatory involvement (Fig. 3). At that time an 8.5F Sachs pigtail catheter with multiple side holes was percutaneously placed in the abscess under real-time ultrasound guidance (Fig. 4). Sixty cubic millimeters of purulent, brick-colored material was aspirated. After percutaneous drainage the patient showed marked clinical improvement. Over 4 weeks he remained afebrile, the white blood cell count returned to normal, and the right hip and abdominal pain resolved. The drain was removed 41 days after placement and the patient was discharged 4 days later with a regimen of oral dicloxacillin. A follow-up CT scan obtained 7 months later showed no evidence of a residual abscess (Fig. 5). An aortogram performed at that time demonstrated an intact graft. The pa339
340
)rournalof VASCULAR SURGERY
Tobin
Fig. 1. CT scan of the abdomen and pelvis with oral and intravenous contrast material. There is an inhomogeneous low density collection in the right peMs, which deviates the right ureter anteriorly (open arrowhead). The right limb of the prosthesis is in the center of the lesion (black
arrowhead).
Fig. 2. Real-time ultrasound of the right pelvis shows the vascular graft (arrows) stlrrounded by a hypoechoic complex collection.
Volume 8 Number 3 September 1988
Percutaneous drainage ofperigraj~ abscess
341
Fig. 3. CT scan 7 days after admission shows an increase in the size of the abscess with inflammatory involvement of the right iliopsoas muscle (arrowheads).
tient is to continue taking oral dicloxycillin,250 mg three times a day, for life. DISCUSSION There have been reports of the successful management of infected grafts by local debridement and antibiotic or povidone-iodine irrigation, u~4 However, this method of treatment is not generally accepted and preferred treatment consists of excision of the infected prosthesis and revascularization. 14 The associated morbidity and mortality rates are high because these patients are debilitated by complications of the infection and other coexisting disorders, such as cardiac or renal dysfunction.3 Graft infections may be classified as perigraft infections, anastomotic-enteric fistula, or nonanastomotic-enteric erosions.2'3 Abscesses in anatomic continuity with a graft can lead to subsequent perigraft infections? The patient reported in this case had a localized collection surrounding the tight limb of an aortobifemoral graft, which, according to findings of CT scanning, ultrasound, and fine needle aspiration, was consistent with a postsurgical hematoma. This collection presumably became infected by hematogenous seeding from the left flank wound infection.
This case illustrates the successful conservative management of a perigraft abscess by percutaneous catheter drainage. The patient was a poor candidate for surgery at the time of presentation because of sepsis, concurrent retroperitoneal and flank abscesses, and a history of severe coronary and peripheral atherosclerotic disease. By clinical evaluation of the groin incisions, and by CT and ultrasound criteria, the proximal and distal anastomotic sites did not appear to be involved. The graft was considered patent by Doppler studies and physical examination. Because there was no evidence of immediate threat of limb ischemia from graft thrombosis, this patient was considered a candidate for a trial of conservative therapy by percutaneous drainage. CT- or ultrasound-guided percutaneous catheter drainage has been shown to be an effective alternative to surgery in the treatment of intraabdominal or retroperitoneal abscesses, ls-17 However, this is the first reported case of percutaneous drainage of an abscess involving a vascular prosthesis. The patient showed marked clinical improvement immediately after drainage and the prosthesis was saved with no evidence of occlusion, pseudoaneurysm formation, anastomotic breakdown, or development of enteric fistulas.
342
Journat of VASCULAR SURGERY
Tobin
Fig. 4. CT scan after percutaneous catheter placement verifies the catheter position within the abscess (arrowheads).
Fig. 5. CT scan performed 7 months later shows no cvidence of residual abscess.
Tim definitive treatment o f infected aortic prosthetic grafts in most cases remains surgical excision. However, this case illustrates that in selected highrisk patients with patent grafts and localized perigraft
infections, conservative treatment by percutaneous catheter drainage may be effective either as definitive treatment or as a temporizing measure before surgery. If the antibiotics have not already been
Volume 8 Number 3 September 1988
started or if the results of blood, urine, or wound cultures are pending, broad-spectrum antibiotics should be given before and after percutaneous drainage. Many different organisms may be responsible for graft infections1,2; adequate antibiotic coverage is necessary until a specific organism is identified and to prevent the complications of bacteremia and septicemia during catheter manipulation, isit A diagnostic needle aspiration for immediate Gram's stain and culture should always be performed before catheter insertion. The choice of appropriate long-term antibiotic coverage should be made on thc basis of the cultures and sensitivity studies of the aspirate. REFERENCES
1. O'Hara PJ, Hertzer NR, Beven EG, Krajewski LP. Surgical management of infected abdominal aortic grafts: review of a 25-year experience. I VASe SUr,G 1986;3:725-31. 2. Talkington CM, Thompson JE. Prevention and management of infected prostheses. Surg Clin North Am 1982;62:51530. 3. Goldstone J. The infected infra-renal aortic graft. Acta Chir Scand 1987;538:72-86. 4. Turnipseed WD, BerkoffHA, Detmer DE, Acher CW, Belzer FO. Arterial graft infections. Delayed vs immediate vascular reconstruction. Arch Surg 1983;118:410-4. 5. Hilton S, Megibow AJ, Naidich DP, Bosniak MA. Computed tomography of the postoperative abdominal aorta. Radiology 1982;145:403-7. 6. Mark A, Moss AA, Lusby R, Kaiser IA. CT evaluation of complications of abdominal aortic surgery. Radiology 1982; 145:409-14.
Percutaneous drainage of perigraft abscess 343
7. Mark AS, McCarthy SM, Moss AA, Price D. Detection of abdominal aortic graft infection: comparison of CT and Inlabeled white blood cell scans. AJR 1985;144:315-8. 8. Cunat JS, Haaga RJ, Rhodes R, Bekeny J, Yousef SE. Periaortic fluid aspiration for recognition of infected graft: preliminary report. AJR 1982;139:251-3. 9. Katz BH, Black RA, Colley DP. CT-guided fine needle aspiration of a pcriaortic collection. J VASC SURG 1987;5: 762-4. 10. Bernhard VM. Management of graft infections following abdominal aortic aneurysm replacement. World J Surg 1980; 4:679-88. 11. Szilagyi DE, Smith RF, Elliott JP, Vrandecic MP. Infection in arterial reconstruction with synthetic grafts. Ann Surg 1972;176:321-32. 12. Liekweg WG Jr, Greenfield LJ. Vascular prosthetic infections: collected experience and results of treatment. Surgery 1977; 81:335-42. 13. Kwaan JHM, Connolly JE. Successful management of prosthetic graft infection with continuous povidone-iodine irrigation. Arch Surg 1981;116:716-9. 14. Knight CD, Farnell MB, Hollier LH. Treatment of aortic graft infection with povidone-iodine irrigation. Mayo Clin Proc 1983;58:472-5. 15. Gerzof SG, Robbins AH, Birkett DH, Johnson WC, Pugatch R,D, Vincent ME. Percutaneous catheter drainage of abdominal abscesses guided by ultrasound and computed tomography. AIR 1979;133:1-8. 16. van Sormenberg E, Mueller PR, Ferrucci JT. Percntaneous drainage of 250 abdominal abscesses and fluid collections. Radiology 1984;151:337-41. 17. Mueller PK, van Sonnenberg E, Ferrucci JT. Percutaneous drainage of 250 abdominal abscesses and fluid collections. Radiology 1984;151:343-7.