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Coronary stent infection — A grave, avoidable complication
Accepted Manuscript Title: Coronary stent infection − a grave, avoidable complication Authors: Jamshed J. Dalal, Aarti Digrajkar, Meenal Hastak, Anvay Mulay, Vidyadhar Lad, Sunil Wani PII: DOI: Reference:
S2468-600X(17)30050-6 http://dx.doi.org/doi:10.1016/j.ihjccr.2017.07.002 IHJCCR 34
To appear in: Received date: Revised date: Accepted date:
6-4-2017 30-5-2017 17-7-2017
Please cite this article as: Jamshed J.Dalal, Aarti Digrajkar, Meenal Hastak, Anvay Mulay, Vidyadhar Lad, Sunil Wani, Coronary stent infection − a grave, avoidable complication (2010), http://dx.doi.org/10.1016/j.ihjccr.2017.07.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Coronary stent infection – a grave, avoidable complication Dr Jamshed J Dalal (1), Dr Aarti Digrajkar (2), Dr Meenal Hastak (3),Dr Anvay Mulay(4), Dr Vidyadhar Lad(5), Dr Sunil Wani(6)
(1)
Director-Cardiac Sciences, Kokilaben hospital,
Mumbai ([email protected])
(2)
Registrar,
Cardiology,
Kokilaben
hospital
([email protected])
(3) Consultant, Histopathology, Kokilaben hospital ([email protected])
(4) Director- Cardiac Surgery, Fortis hospital, Mumbai
(5) Consultant, cardiac surgery, Kokilaben hospital ([email protected])
(6) Consultant cardiologist, kokilaben hospital ([email protected])
Author for correspondence Dr Jamshed J Dalal [email protected] 9821012409
We present two cases where patients underwent a coronary angioplasty (PCI) in the year 2016 and developed stent infection and coronary artery aneurysm r leading to serious consequences requiring surgical removal of the stent and aneurysm and extensive hospitalization and prolonged antibiotic therapy. Case 1 A 66-year-old lady presented with an acute inferior myocardial infarction. She had a history of diabetes and hypertension. Her coronary angiography revealed the left anterior descending and circumflex artery to be normal. The right coronary artery (RCA) had a 95% lesion. She underwent a PCI and a GEN X SYNC Sirolimus drugeluting stent (3X19mm) was implanted. She was discharged the next day. She presented again one month later with rest angina and minor ST changes in the inferior leads. She had no fever and her WBC counts were normal. Coronary angiography revealed a totally occluded RCA with a large aneurysm. (Fig 1) She underwent CABG next day with removal of the stent and coronary aneurysm and a single SVG graft to the RCA. The stent was floating in pus and easily removed. Culture of the stent grew pseudomonas aeruginosa. As per sensitivity, she was treated with intravenous (IV) Meropenum, IV Amikacin and IV Cefepime and discharged ten days later on antibiotics.
Histopathology of the aneurysmal tissue showed acute inflammatory infiltrate with infected granulation tissue. She was again hospitalized two weeks later in a septic shock state, with high fever and raised WBC count. She developed atrial fibrillation and fall in ejection fraction to 30% and required inotropic support. Repeat blood cultures showed the same organism and same sensitivity pattern and the triple antibiotic regimen was continued. She had a protracted stay and slow recovery but was eventually discharge in good health with all three antibiotics continued for a total of six weeks duration. She has since remained well on follow up. Case 2 A 50-year-old male with a long-standing history of diabetes and hypertension underwent an uneventful PCI to circumflex artery for stable angina with a Promus stent implantation. One month later he presented with a three day history of fever and on reaching hospital developed acute left ventricular failure followed by cardiac arrest. As he was in the hospital at the time, he was quickly revived, but due to hypotension required an IABP insertion and ventilation. His Left ventricular ejection fraction was 50 %. Coronary angiography showed an occluded circumflex artery with a coronary aneurysm at the site of the stent implantation (Fig 2). A CT coronary angiography was done prior to surgery, which showed a aneurysmal sack with the stent appearing to lie within it. (Fig 3) Using the help of an intraoperative transesophageal echocardiography (Fig 4) he underwent surgery with removal of the stent and a 3 by 4 cm aneurysm filled with organized clots and necrotic debris. The proximal end of the stent was lying free in the aneurysm, while the distal end was in the distal circumflex. No graft was put into the distal circumflex as it was found to be small and diseased. His culture grew pseudomonas
aeruginosa and staphylococcus warneri. He was given protracted antibiotic treatment with IV Ceftazidine 2 gm thrice a day, IV gentamycin 80 mg thrice a day and IV Vancomycin 1 gm twice a day. After two weeks the gentamycin was stopped as he showed Ototoxicity. The remaining antibiotics were continued for six weeks and the patient eventually recovered fully. Discussion Cases of stent infections though rare, have been reported in literature. Stent infection is another rare but important cause for coronary aneurysms, (1) (Table 1) and is more likely to be seen in countries that reuse catheters or have poor sterilization standards. In 2003, Liu et al, reported for the first time an infected bare-metal stent presenting as a coronary artery mycotic aneurysm (2). Earlier reported cases of coronary stent infection had not describe mycotic aneurysms. Marc Elieson et al, presented a case of stent infection(3) and Aaron Schoenkerman and others, (4) presented three cases of coronary stent infection with dramatic consequences. Two cases were complicated by rupture of a coronary mycotic aneurysm into an adjacent cardiac chamber, diagnosed during coronary angiography. One of these aneurysms occurred at the site of a drug eluting stent, and the other at that of a bare-metal stent. Of the risk factors, age over 60 years and the presence of congestive heart failure may have played a role in two of these cases. As in previously reported cases of stent infection, myocardial infarction was present and surgical intervention was necessary for patient survival. Two of their three patients died. They suggested that stent-related infection be included in the differential diagnosis of fever of unknown origin, especially in the setting of
staphylococcus aureus bacteremia. In their series, as in others and in one of our cases, staphylococcus aureus was the infecting organism.
In 2005, Kaufmann compiled 10 reported cases and reviewed the risk factors, clinical presentation, diagnosis, therapy, and prognosis of coronary stent infection including the first case of a drug-eluting stent infection. (5) Infection appeared between two days and four weeks after the procedure. The symptoms included fever in all subjects and chest pain in five. Two patients suffered acute myocardial infarction. All patients showed positive blood cultures. Seven patients had staphylococcus aureus, whereas in two, pseudomonas aeruginosa was grown. Based on the currently available data, mortality may be as high as 40% despite antibiotic and or surgical treatment. Similar to our two cases, the presentation in most cases is within few weeks of stent implantation. It is important to note that our first patient presented with angina rather than infective symptoms and infection was diagnosed only after the angiographic findings. Also important to note that in spite of removal of the aneurysm and the stent and starting antibiotics the patient was rehospitalised with severe complications. This suggests need for prolonged intensive therapy and close follow up. Literature also shows poor prognosis of these patients highlighting the need for urgent intensive prolonged therapy. The second patient presented with left ventricular failure and cardiac arrest and was once again diagnosed only after the coronary angiography. Though he had been having fever for three days prior, the diagnosis was made on angiography rather than on clinical grounds. This raises the concern that patients with infected stents may
be missed as their presentations vary and it is the angiographic findings, which help to confirm the diagnosis. Both these patients presented to cardiologist and this may be the reason for the early angiography. Patients with implanted stents may present to physicians who may investigate extensively for causes of fever and still possibly miss an infected coronary stent infection till a coronary event occurs. Another worrying presentation is of a series of five patients described by Soman et al, who were diagnosed with endocarditis due to atypical mycobacteria. (6) They postulate that these were related to the reuse of PCI hardware. Sterilization of catheters in “Cidex” solution with water contaminated with atypical mycobacteria may be a probable cause of this infection. There was significant diagnostic and therapeutic difficulties and uniformly dismal outcome in this series of mycobacterial endocarditis. They underlined the potential hazards of re-use of single-use devices and the unusual organisms that one may see in this part of the world. This raises the importance of proper sterilization techniques of reuse hardware. The most probable reason for stent infection may be either reuse of one time use devices such as balloons, or due to aseptic techniques during the procedure. Both our patients were earlier done in smaller institutions and reuse is a strong possibility, however confirmation of this fact could not be obtained. Staphylococcus aureus and pseudomonas aeruginosa are the common organisms reported in literature and were present in both our cases. Reuse of catheters to save cost, is a debatable issue and various guide lines have been made to use standardized sterilization techniques. However recent government of India policies have made it clear that reuse of one time
use equipment is illegal and therefore there is no justification for their reuse. Conclusion Stent infection is a serious problem with a high morbidity and mortality. It is important to diagnose the problem early, as the patient may manifest with variable presentations not always pointing to the stent. Our two patients were diagnosed early as they presented to a cardiologist and underwent early coronary angiography with out which the diagnosis may have been delayed or missed. In my opinion it would be wise to rule out stent infection by coronary angiography in all patients who have had a stent implanted recently and present with fever of unknown etiology even if they have no cardiac complaints at the time of presentation. A full six-week or longer appropriate antibiotic course must be implemented to prevent relapse. Additional problem of mycobacterial and other unusual organisms further compounds the problem and must be considered when routine organism is not found in the culture. The infected stent must be removed at time of surgery and cultured so that appropriate therapy can be administered. More, importantly, all attempts must be made to prevent it. Good aseptic care and avoiding reuse of single use catheters is the best preventive measure. In countries where reuse is necessary due to circumstances, strong guidelines for catheter sterilization need to be followed. Present government policy is that reuse of one time catheters is not to be practiced. Conflict of Interest There is no conflict of interest of any authors of this case report
References 1) Common Causes of Coronary Artery Aneurysms CT Angiography Of Coronary Artery Aneurysms Johnson PT, Fishman EK Am J of Roent; vol 195, 2010 2) Coronary abscess: A complication of stenting. Liu JC, Cziperle DJ, Kleinman B, Loeb H. Catheter Cardiovasc Interv 2003; 58: 69-71
3) Coronary Stent Infections A Case Report and Literature Review Marc Elieson, Timothy Mixon, and John Carpenter Tex Heart Inst J. 2012; 39(6): 884–889 4) Coronary stent infections: A case series Aaron B. Schoenkerman, Robert J. Lundstrom Catheterization and Cardiovascular Interventions Ultima actualizacion: 28 DE ENERO DE 2009 5) Coronary stent infection: a rare but severe complication of percutaneous coronary intervention Beat A. Kaufmann, Christopher Kaiser, Matthias E. Pfisterer, Piero O. Bonetti Swiss Med Wkly 2005 Aug 20; 135(33-34): 483-7 6) Intravascular Stent-related Endocarditis due to Rapidly Growing Mycobacteria: A New Problem in the Developing World Rajeev Soman, Neha Gupta, Mitesh Suthar, Ayesha Sunavala, Anjali Shetty, Camilla Rodrigues JAPI 2015 Jan; 63(1): 18-21
Fig. 1
Fig. 2
Fig. 3
Fig. 4
Common Causes of Coronary Artery Aneurysms Ct Angiography Of Coronary Artery Aneurysms: (Am J of Roent; vol 195, 2010) • • • • • • • • • •
Atherosclerosis Kawasaki disease Takayasu vasculitis Systemic lupus erythematosus Rheumatic fever Infections Congenital abnormality Trauma Polyarteritis nodosa Cocaine use
S2468-600X(17)30050-6 http://dx.doi.org/doi:10.1016/j.ihjccr.2017.07.002 IHJCCR 34
To appear in: Received date: Revised date: Accepted date:
6-4-2017 30-5-2017 17-7-2017
Please cite this article as: Jamshed J.Dalal, Aarti Digrajkar, Meenal Hastak, Anvay Mulay, Vidyadhar Lad, Sunil Wani, Coronary stent infection − a grave, avoidable complication (2010), http://dx.doi.org/10.1016/j.ihjccr.2017.07.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Coronary stent infection – a grave, avoidable complication Dr Jamshed J Dalal (1), Dr Aarti Digrajkar (2), Dr Meenal Hastak (3),Dr Anvay Mulay(4), Dr Vidyadhar Lad(5), Dr Sunil Wani(6)
(1)
Director-Cardiac Sciences, Kokilaben hospital,
Mumbai ([email protected])
(2)
Registrar,
Cardiology,
Kokilaben
hospital
([email protected])
(3) Consultant, Histopathology, Kokilaben hospital ([email protected])
(4) Director- Cardiac Surgery, Fortis hospital, Mumbai
(5) Consultant, cardiac surgery, Kokilaben hospital ([email protected])
(6) Consultant cardiologist, kokilaben hospital ([email protected])
Author for correspondence Dr Jamshed J Dalal [email protected] 9821012409
We present two cases where patients underwent a coronary angioplasty (PCI) in the year 2016 and developed stent infection and coronary artery aneurysm r leading to serious consequences requiring surgical removal of the stent and aneurysm and extensive hospitalization and prolonged antibiotic therapy. Case 1 A 66-year-old lady presented with an acute inferior myocardial infarction. She had a history of diabetes and hypertension. Her coronary angiography revealed the left anterior descending and circumflex artery to be normal. The right coronary artery (RCA) had a 95% lesion. She underwent a PCI and a GEN X SYNC Sirolimus drugeluting stent (3X19mm) was implanted. She was discharged the next day. She presented again one month later with rest angina and minor ST changes in the inferior leads. She had no fever and her WBC counts were normal. Coronary angiography revealed a totally occluded RCA with a large aneurysm. (Fig 1) She underwent CABG next day with removal of the stent and coronary aneurysm and a single SVG graft to the RCA. The stent was floating in pus and easily removed. Culture of the stent grew pseudomonas aeruginosa. As per sensitivity, she was treated with intravenous (IV) Meropenum, IV Amikacin and IV Cefepime and discharged ten days later on antibiotics.
Histopathology of the aneurysmal tissue showed acute inflammatory infiltrate with infected granulation tissue. She was again hospitalized two weeks later in a septic shock state, with high fever and raised WBC count. She developed atrial fibrillation and fall in ejection fraction to 30% and required inotropic support. Repeat blood cultures showed the same organism and same sensitivity pattern and the triple antibiotic regimen was continued. She had a protracted stay and slow recovery but was eventually discharge in good health with all three antibiotics continued for a total of six weeks duration. She has since remained well on follow up. Case 2 A 50-year-old male with a long-standing history of diabetes and hypertension underwent an uneventful PCI to circumflex artery for stable angina with a Promus stent implantation. One month later he presented with a three day history of fever and on reaching hospital developed acute left ventricular failure followed by cardiac arrest. As he was in the hospital at the time, he was quickly revived, but due to hypotension required an IABP insertion and ventilation. His Left ventricular ejection fraction was 50 %. Coronary angiography showed an occluded circumflex artery with a coronary aneurysm at the site of the stent implantation (Fig 2). A CT coronary angiography was done prior to surgery, which showed a aneurysmal sack with the stent appearing to lie within it. (Fig 3) Using the help of an intraoperative transesophageal echocardiography (Fig 4) he underwent surgery with removal of the stent and a 3 by 4 cm aneurysm filled with organized clots and necrotic debris. The proximal end of the stent was lying free in the aneurysm, while the distal end was in the distal circumflex. No graft was put into the distal circumflex as it was found to be small and diseased. His culture grew pseudomonas
aeruginosa and staphylococcus warneri. He was given protracted antibiotic treatment with IV Ceftazidine 2 gm thrice a day, IV gentamycin 80 mg thrice a day and IV Vancomycin 1 gm twice a day. After two weeks the gentamycin was stopped as he showed Ototoxicity. The remaining antibiotics were continued for six weeks and the patient eventually recovered fully. Discussion Cases of stent infections though rare, have been reported in literature. Stent infection is another rare but important cause for coronary aneurysms, (1) (Table 1) and is more likely to be seen in countries that reuse catheters or have poor sterilization standards. In 2003, Liu et al, reported for the first time an infected bare-metal stent presenting as a coronary artery mycotic aneurysm (2). Earlier reported cases of coronary stent infection had not describe mycotic aneurysms. Marc Elieson et al, presented a case of stent infection(3) and Aaron Schoenkerman and others, (4) presented three cases of coronary stent infection with dramatic consequences. Two cases were complicated by rupture of a coronary mycotic aneurysm into an adjacent cardiac chamber, diagnosed during coronary angiography. One of these aneurysms occurred at the site of a drug eluting stent, and the other at that of a bare-metal stent. Of the risk factors, age over 60 years and the presence of congestive heart failure may have played a role in two of these cases. As in previously reported cases of stent infection, myocardial infarction was present and surgical intervention was necessary for patient survival. Two of their three patients died. They suggested that stent-related infection be included in the differential diagnosis of fever of unknown origin, especially in the setting of
staphylococcus aureus bacteremia. In their series, as in others and in one of our cases, staphylococcus aureus was the infecting organism.
In 2005, Kaufmann compiled 10 reported cases and reviewed the risk factors, clinical presentation, diagnosis, therapy, and prognosis of coronary stent infection including the first case of a drug-eluting stent infection. (5) Infection appeared between two days and four weeks after the procedure. The symptoms included fever in all subjects and chest pain in five. Two patients suffered acute myocardial infarction. All patients showed positive blood cultures. Seven patients had staphylococcus aureus, whereas in two, pseudomonas aeruginosa was grown. Based on the currently available data, mortality may be as high as 40% despite antibiotic and or surgical treatment. Similar to our two cases, the presentation in most cases is within few weeks of stent implantation. It is important to note that our first patient presented with angina rather than infective symptoms and infection was diagnosed only after the angiographic findings. Also important to note that in spite of removal of the aneurysm and the stent and starting antibiotics the patient was rehospitalised with severe complications. This suggests need for prolonged intensive therapy and close follow up. Literature also shows poor prognosis of these patients highlighting the need for urgent intensive prolonged therapy. The second patient presented with left ventricular failure and cardiac arrest and was once again diagnosed only after the coronary angiography. Though he had been having fever for three days prior, the diagnosis was made on angiography rather than on clinical grounds. This raises the concern that patients with infected stents may
be missed as their presentations vary and it is the angiographic findings, which help to confirm the diagnosis. Both these patients presented to cardiologist and this may be the reason for the early angiography. Patients with implanted stents may present to physicians who may investigate extensively for causes of fever and still possibly miss an infected coronary stent infection till a coronary event occurs. Another worrying presentation is of a series of five patients described by Soman et al, who were diagnosed with endocarditis due to atypical mycobacteria. (6) They postulate that these were related to the reuse of PCI hardware. Sterilization of catheters in “Cidex” solution with water contaminated with atypical mycobacteria may be a probable cause of this infection. There was significant diagnostic and therapeutic difficulties and uniformly dismal outcome in this series of mycobacterial endocarditis. They underlined the potential hazards of re-use of single-use devices and the unusual organisms that one may see in this part of the world. This raises the importance of proper sterilization techniques of reuse hardware. The most probable reason for stent infection may be either reuse of one time use devices such as balloons, or due to aseptic techniques during the procedure. Both our patients were earlier done in smaller institutions and reuse is a strong possibility, however confirmation of this fact could not be obtained. Staphylococcus aureus and pseudomonas aeruginosa are the common organisms reported in literature and were present in both our cases. Reuse of catheters to save cost, is a debatable issue and various guide lines have been made to use standardized sterilization techniques. However recent government of India policies have made it clear that reuse of one time
use equipment is illegal and therefore there is no justification for their reuse. Conclusion Stent infection is a serious problem with a high morbidity and mortality. It is important to diagnose the problem early, as the patient may manifest with variable presentations not always pointing to the stent. Our two patients were diagnosed early as they presented to a cardiologist and underwent early coronary angiography with out which the diagnosis may have been delayed or missed. In my opinion it would be wise to rule out stent infection by coronary angiography in all patients who have had a stent implanted recently and present with fever of unknown etiology even if they have no cardiac complaints at the time of presentation. A full six-week or longer appropriate antibiotic course must be implemented to prevent relapse. Additional problem of mycobacterial and other unusual organisms further compounds the problem and must be considered when routine organism is not found in the culture. The infected stent must be removed at time of surgery and cultured so that appropriate therapy can be administered. More, importantly, all attempts must be made to prevent it. Good aseptic care and avoiding reuse of single use catheters is the best preventive measure. In countries where reuse is necessary due to circumstances, strong guidelines for catheter sterilization need to be followed. Present government policy is that reuse of one time catheters is not to be practiced. Conflict of Interest There is no conflict of interest of any authors of this case report
References 1) Common Causes of Coronary Artery Aneurysms CT Angiography Of Coronary Artery Aneurysms Johnson PT, Fishman EK Am J of Roent; vol 195, 2010 2) Coronary abscess: A complication of stenting. Liu JC, Cziperle DJ, Kleinman B, Loeb H. Catheter Cardiovasc Interv 2003; 58: 69-71
3) Coronary Stent Infections A Case Report and Literature Review Marc Elieson, Timothy Mixon, and John Carpenter Tex Heart Inst J. 2012; 39(6): 884–889 4) Coronary stent infections: A case series Aaron B. Schoenkerman, Robert J. Lundstrom Catheterization and Cardiovascular Interventions Ultima actualizacion: 28 DE ENERO DE 2009 5) Coronary stent infection: a rare but severe complication of percutaneous coronary intervention Beat A. Kaufmann, Christopher Kaiser, Matthias E. Pfisterer, Piero O. Bonetti Swiss Med Wkly 2005 Aug 20; 135(33-34): 483-7 6) Intravascular Stent-related Endocarditis due to Rapidly Growing Mycobacteria: A New Problem in the Developing World Rajeev Soman, Neha Gupta, Mitesh Suthar, Ayesha Sunavala, Anjali Shetty, Camilla Rodrigues JAPI 2015 Jan; 63(1): 18-21
Fig. 1
Fig. 2
Fig. 3
Fig. 4
Common Causes of Coronary Artery Aneurysms Ct Angiography Of Coronary Artery Aneurysms: (Am J of Roent; vol 195, 2010) • • • • • • • • • •
Atherosclerosis Kawasaki disease Takayasu vasculitis Systemic lupus erythematosus Rheumatic fever Infections Congenital abnormality Trauma Polyarteritis nodosa Cocaine use