- Email: [email protected]
Coronary Stent Infection Successfully Diagnosed Using 18F-Flurodeoxyglucose Positron Emission Tomography Computed Tomography
Accepted Manuscript Coronary Stent Infection Successfully diagnosed with FDG-PET CT Dr. Saritha Sekhar, MD, DNB, Associate Professor, Dr. Anjith Vupputuri, MD, DM, Dr. C. Rajiv, MD, DM, Professor, Dr. P. Shanmuga Sundaram., DRM, DNB, Professor, Dr. K.U. Natarajan, MD, DM, DNB PII:
S0828-282X(15)01565-2
DOI:
10.1016/j.cjca.2015.10.022
Reference:
CJCA 1913
To appear in:
Canadian Journal of Cardiology
Received Date: 5 May 2015 Revised Date:
26 October 2015
Accepted Date: 26 October 2015
Please cite this article as: Sekhar S, Vupputuri A, Rajiv C, Shanmuga Sundaram P, Natarajan KU, Coronary Stent Infection Successfully diagnosed with FDG-PET CT, Canadian Journal of Cardiology (2015), doi: 10.1016/j.cjca.2015.10.022. 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.
ACCEPTED MANUSCRIPT Title Page Type of Manuscript: Case Report Title of Article: Coronary Stent Infection Successfully diagnosed with FDG-PET CT Short title: Coronary stent infection diagnosed with FDG-PET CT
Associate Professor, Department of Cardiology Amrita Institute of Medical Sciences, Kochi Amrita Vishwa Vidyapeetham University
Department of Cardiology
M AN U
2. Dr. Anjith Vupputuri MD, DM
Amrita Institute of Medical Sciences, Kochi Amrita Vishwa Vidyapeetham University 3. Dr. Rajiv. C MD, DM
SC
1. Dr. Saritha Sekhar MD, DNB
RI PT
Names of contributors:
TE D
Professor, Department of Cardiology
Amrita Institute of Medical Sciences, Kochi Amrita Vishwa Vidyapeetham University
EP
4. Dr. Shanmuga Sundaram . P DRM, DNB Professor, Department of Nuclear Medicine
AC C
Amrita Institute of Medical Sciences, Kochi Amrita Vishwa Vidyapeetham University 5. Dr. K.U. Natarajan MD, DM, DNB Professor, Department of Cardiology Amrita Institute of Medical Sciences, Kochi Amrita Vishwa Vidyapeetham University
ACCEPTED MANUSCRIPT
Total number of pages: 4 Total number of Words: Brief Summary- 61
RI PT
Abstract – 99 Text – 905(Excluding abstract, Brief Summary and references) Number of Figures:
2 (1 color figure)
External source of funding: Nil
Dr. K.U. Natarajan MD,DM,DNB
M AN U
Corresponding Author:
SC
Conflicts of interest: Nil
Department of Cardiology
Amrita Institute of Medical Sciences, Kochi Kerala, India -682041
TE D
Phone- +91-9400166999(cell) E-mail id : [email protected]
AC C
EP
[email protected]
ACCEPTED MANUSCRIPT
Coronary Stent Infection successfully diagnosed with FDG-PET CT
RI PT
Brief Summary
We report a case of a 60-year-old gentleman with recurrent fever following acute stent
occlusion and reintervention. Coronary angiogram showed an occluded stented segment and the blood cultures were positive. The presence of inflammation in the stented region
SC
was confirmed using 18F-flurodeoxyglucose Positron emission tomography CT. The
patient underwent surgery and the diagnosis was proved by examination of the surgical
M AN U
material.
Abstract
Infection of coronary stents is extremely rare. We report a case of a 60-year-old gentleman with recurrent fever following acute stent occlusion and reintervention. Coronary angiogram (CAG) showed an occluded stented segment and the blood cultures
TE D
were positive. The presence of inflammation in the stented region was confirmed using 18F-flurodeoxyglucose (FDG) Positron emission tomography (PET) CT. The patient underwent surgery and the diagnosis was proved by examination of the surgical material. This article highlights the need to have a high index of suspicion of stent infection, and
EP
the utilization of FDG-PET CT along with CAG in aiding the diagnosis.
AC C
Key words: Stent infection, FDG-PET CT, Coronary angioplasty Introduction
Percutaneous transluminal coronary angioplasty (PTCA) is a prevalent treatment option for coronary artery disease. Stent infection, though rare, is hard to diagnose and treat. The prognosis is very poor with >50% mortality.1 Various modalities such as transesophageal echocardiography (TEE), CT coronary angiogram and conventional coronary angiogram (CAG) were described for the diagnosis, but none of these modalities indicate active infection or inflammation in the stented segment. We report a unique case of stent infection with stent abscess diagnosed by TEE and 18F-flurodeoxyglucose (FDG)
ACCEPTED MANUSCRIPT Positron emission tomography (PET) CT. Case Report A 60-year-old gentleman presented to a local hospital elsewhere with stable angina. His coronary angiogram (CAG) showed single vessel disease with two tubular lesions in the right coronary artery (RCA) and he underwent PTCA with 3 drug eluting stents (DES).
RI PT
He was readmitted with high-grade fever and acute inferior wall STEMI. A repeat CAG showed acute stent thrombosis. Thrombus aspiration was attempted but was unsuccessful. Hence, intracoronary streptokinase followed by systemic thrombolysis was performed. The patient subsequently developed large pericardial effusion, and underwent The
blood
cultures
were
sterile.
The
patient
improved
SC
pericardiocentesis.
symptomatically and was discharged after 3 weeks of intravenous (IV) antibiotics. The patient was readmitted with fever within 15 days after discharge. The blood culture grew
complete occlusion of the RCA.
M AN U
Pseudomonas aeuroginosa and was treated as per sensitivity. A CT angiogram showed
The patient was referred to our Institute with a provisional diagnosis of probable stent infection. The blood culture grew Enterobacter cloacae complex and was treated as per sensitivity. TEE showed prominent and dilated right atrioventricular (AV) groove (1.5 x 1.5 cm) with a rounded echogenic structure (possibly a stent abscess) with a thin jet of
TE D
continuous flow into the right atrium (RA) from the right AV groove, and small vegetation at the base of the anterior tricuspid leaflet (Figure 1, Video S1 and S2 in Supplementary Materials). In order to confirm that the stented segment is the source of infection, a FDG-PET CT scan was done, which showed abnormal FDG uptake in and
EP
around the mid, distal RCA stent region and in the pericardial cavity adjacent to the mid
AC C
RCA stent, suggestive of an active infective or inflammatory pathology (Figure 2).
He was sent for surgery. The abscess cavity was deroofed, the infected 3 stents were removed and bypass grafting was done to distal RCA. The abscess cavity was closed using pedicled omentum. The tricuspid valve vegetations were shaved off, and the fistulous tract was closed. A culture of the tricuspid valve vegetation, pus and AV groove tissue revealed heavy growth of Enterobacter species. He is currently asymptomatic and has been under regular follow up for the last 18 months after surgery.
ACCEPTED MANUSCRIPT Discussion Since the advent of PTCA and the subsequent introduction of coronary stents, PTCA has become one the most prevalent cardiac interventions carried out today. The low infection rate of coronary artery stents was proposed to be a result of the inflammatory nature of atherosclerosis, which may provide a protective benefit against bacterial infection of the
RI PT
stent and the overall low incidence of infection in percutaneous procedures. Stent infections are rare, with only 17 reports from 1990-2012. Subclinical infections and under-reporting may be possible reasons for such a low incidence.1
SC
The goals of the evaluation of a patient with a potential stent infection include making a clinical, radiographic and microbiologic diagnosis, detecting complications, and determining optimal therapy. Dieter et al.2 proposed criteria for the diagnosis of coronary
M AN U
stent infection. A definitive diagnosis can be made by autopsy or by examination of the surgical material. For possible diagnosis, 3 of the following criteria must be present: placement of a coronary stent within the previous 4 weeks; multiple repeat procedures performed through the same arterial sheath; the presence of bacteremia, significant fever, or leukocytosis with no other cause; acute coronary syndrome; or positive cardiac imaging. Our patient fitted into the possible diagnosis of stent infection initially, and
TE D
hence was started on antibiotic therapy.
Although positive blood cultures are diagnostic of infection, they do not identify the anatomic source of the infection. TEE, CT scan, CAG and cardiac MRI were initially
EP
proposed to make the diagnosis of stent infection and complications.1 However, these modalities identify only stent occlusion, or an abscess if present. To pinpoint the stented
AC C
segment as the source of infection, we used FDG-PET CT, which showed an abnormal FDG uptake indicating active infection or inflammation. FDG-PET CT is a proven modality in identifying occult inflammation in the body.3,4 However, patients with recent acute coronary syndrome (ACS) were found to have an increased FDG uptake within the culprit lesion.5 Differentiating stent thrombosis from stent infection on PET is extremely difficult. The diagnosis is based on the clinical scenario and other collaborative investigations. PET images in stent thrombosis suggest that in this condition, the FDG uptake is localized only to the stented region of the vessel, whereas in stent infection it is diffuse involving the surrounding soft tissue as well.
ACCEPTED MANUSCRIPT Surgery was decided for our patient as symptoms persisted with recurrent fever, positive blood culture and TEE revealing stent abscess and fistula. Stent infection, although rare, should be suspected in patients with persisting fever postPTCA. A complete evaluation with blood cultures must be carried out and adequate broad-spectrum antibiotics started. FDG-PET CT appears to be a useful modality aiding
RI PT
the diagnosis. Surgery must be considered in persistent stent infections, especially if major complications are apparent on the angiogram and/or TEE.
SC
References
1. Elieson M, Mixon T, Carpenter J. Coronary stent infections: a case report and
M AN U
literature review. Tex Heart Inst J 2012;39:884-9.
2. Dieter RS. Coronary artery stent infection. Clin Cardiol 2000;23:808-10. 3. Glaudemans AW, Signore A. FDG-PET/CT in infections: the imaging method of choice? Eur J Nucl Med Mol Imaging 2010;37:1986-91.
4. Kubota K, Nakamoto Y, Tamaki N, et al. FDG-PET for the diagnosis of fever of
TE D
unknown origin: a Japanese multi- center study. Ann Nucl Med 2011;25:355-64. 5. Cheng VY, Slomka PJ, Le Meunier L, et al. Coronary arterial 18F-FDG uptake by fusion of PET and coronary CT angiography at sites of percutaneous stenting for acute myocardial infarction and stable coronary artery disease. J Nucl Med
AC C
EP
2012;53:575-83.
Figure captions
ACCEPTED MANUSCRIPT Figure 1: Trans esophageal echocardiography image showing dilated proximal right coronary artery with stent abscess (black arrow) and vegetation on anterior tricuspid leaflet (white arrow). Figure 2: FDG-PET CT image showing abnormal FDG uptake in and around RCA stent
value (SUV) max of lesion 7.3, SUV mean 4.2).
M AN U
SC
.
RI PT
region suggestive of an active infective or inflammatory pathology (Standardized uptake
Legend for videos in Supplementary Materials
TE D
Video S1: Trans esophageal echocardiography video showing dilated proximal right coronary artery with stent abscess and vegetation on the base of anterior tricuspid leaflet. Video S2: Trans esophageal echocardiography color Doppler video showing dilated proximal right coronary artery (RCA) with stent abscess and a thin jet of continuous flow
AC C
EP
into the right atrium (RA) indicating the presence of RCA to RA fistula.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0828-282X(15)01565-2
DOI:
10.1016/j.cjca.2015.10.022
Reference:
CJCA 1913
To appear in:
Canadian Journal of Cardiology
Received Date: 5 May 2015 Revised Date:
26 October 2015
Accepted Date: 26 October 2015
Please cite this article as: Sekhar S, Vupputuri A, Rajiv C, Shanmuga Sundaram P, Natarajan KU, Coronary Stent Infection Successfully diagnosed with FDG-PET CT, Canadian Journal of Cardiology (2015), doi: 10.1016/j.cjca.2015.10.022. 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.
ACCEPTED MANUSCRIPT Title Page Type of Manuscript: Case Report Title of Article: Coronary Stent Infection Successfully diagnosed with FDG-PET CT Short title: Coronary stent infection diagnosed with FDG-PET CT
Associate Professor, Department of Cardiology Amrita Institute of Medical Sciences, Kochi Amrita Vishwa Vidyapeetham University
Department of Cardiology
M AN U
2. Dr. Anjith Vupputuri MD, DM
Amrita Institute of Medical Sciences, Kochi Amrita Vishwa Vidyapeetham University 3. Dr. Rajiv. C MD, DM
SC
1. Dr. Saritha Sekhar MD, DNB
RI PT
Names of contributors:
TE D
Professor, Department of Cardiology
Amrita Institute of Medical Sciences, Kochi Amrita Vishwa Vidyapeetham University
EP
4. Dr. Shanmuga Sundaram . P DRM, DNB Professor, Department of Nuclear Medicine
AC C
Amrita Institute of Medical Sciences, Kochi Amrita Vishwa Vidyapeetham University 5. Dr. K.U. Natarajan MD, DM, DNB Professor, Department of Cardiology Amrita Institute of Medical Sciences, Kochi Amrita Vishwa Vidyapeetham University
ACCEPTED MANUSCRIPT
Total number of pages: 4 Total number of Words: Brief Summary- 61
RI PT
Abstract – 99 Text – 905(Excluding abstract, Brief Summary and references) Number of Figures:
2 (1 color figure)
External source of funding: Nil
Dr. K.U. Natarajan MD,DM,DNB
M AN U
Corresponding Author:
SC
Conflicts of interest: Nil
Department of Cardiology
Amrita Institute of Medical Sciences, Kochi Kerala, India -682041
TE D
Phone- +91-9400166999(cell) E-mail id : [email protected]
AC C
EP
[email protected]
ACCEPTED MANUSCRIPT
Coronary Stent Infection successfully diagnosed with FDG-PET CT
RI PT
Brief Summary
We report a case of a 60-year-old gentleman with recurrent fever following acute stent
occlusion and reintervention. Coronary angiogram showed an occluded stented segment and the blood cultures were positive. The presence of inflammation in the stented region
SC
was confirmed using 18F-flurodeoxyglucose Positron emission tomography CT. The
patient underwent surgery and the diagnosis was proved by examination of the surgical
M AN U
material.
Abstract
Infection of coronary stents is extremely rare. We report a case of a 60-year-old gentleman with recurrent fever following acute stent occlusion and reintervention. Coronary angiogram (CAG) showed an occluded stented segment and the blood cultures
TE D
were positive. The presence of inflammation in the stented region was confirmed using 18F-flurodeoxyglucose (FDG) Positron emission tomography (PET) CT. The patient underwent surgery and the diagnosis was proved by examination of the surgical material. This article highlights the need to have a high index of suspicion of stent infection, and
EP
the utilization of FDG-PET CT along with CAG in aiding the diagnosis.
AC C
Key words: Stent infection, FDG-PET CT, Coronary angioplasty Introduction
Percutaneous transluminal coronary angioplasty (PTCA) is a prevalent treatment option for coronary artery disease. Stent infection, though rare, is hard to diagnose and treat. The prognosis is very poor with >50% mortality.1 Various modalities such as transesophageal echocardiography (TEE), CT coronary angiogram and conventional coronary angiogram (CAG) were described for the diagnosis, but none of these modalities indicate active infection or inflammation in the stented segment. We report a unique case of stent infection with stent abscess diagnosed by TEE and 18F-flurodeoxyglucose (FDG)
ACCEPTED MANUSCRIPT Positron emission tomography (PET) CT. Case Report A 60-year-old gentleman presented to a local hospital elsewhere with stable angina. His coronary angiogram (CAG) showed single vessel disease with two tubular lesions in the right coronary artery (RCA) and he underwent PTCA with 3 drug eluting stents (DES).
RI PT
He was readmitted with high-grade fever and acute inferior wall STEMI. A repeat CAG showed acute stent thrombosis. Thrombus aspiration was attempted but was unsuccessful. Hence, intracoronary streptokinase followed by systemic thrombolysis was performed. The patient subsequently developed large pericardial effusion, and underwent The
blood
cultures
were
sterile.
The
patient
improved
SC
pericardiocentesis.
symptomatically and was discharged after 3 weeks of intravenous (IV) antibiotics. The patient was readmitted with fever within 15 days after discharge. The blood culture grew
complete occlusion of the RCA.
M AN U
Pseudomonas aeuroginosa and was treated as per sensitivity. A CT angiogram showed
The patient was referred to our Institute with a provisional diagnosis of probable stent infection. The blood culture grew Enterobacter cloacae complex and was treated as per sensitivity. TEE showed prominent and dilated right atrioventricular (AV) groove (1.5 x 1.5 cm) with a rounded echogenic structure (possibly a stent abscess) with a thin jet of
TE D
continuous flow into the right atrium (RA) from the right AV groove, and small vegetation at the base of the anterior tricuspid leaflet (Figure 1, Video S1 and S2 in Supplementary Materials). In order to confirm that the stented segment is the source of infection, a FDG-PET CT scan was done, which showed abnormal FDG uptake in and
EP
around the mid, distal RCA stent region and in the pericardial cavity adjacent to the mid
AC C
RCA stent, suggestive of an active infective or inflammatory pathology (Figure 2).
He was sent for surgery. The abscess cavity was deroofed, the infected 3 stents were removed and bypass grafting was done to distal RCA. The abscess cavity was closed using pedicled omentum. The tricuspid valve vegetations were shaved off, and the fistulous tract was closed. A culture of the tricuspid valve vegetation, pus and AV groove tissue revealed heavy growth of Enterobacter species. He is currently asymptomatic and has been under regular follow up for the last 18 months after surgery.
ACCEPTED MANUSCRIPT Discussion Since the advent of PTCA and the subsequent introduction of coronary stents, PTCA has become one the most prevalent cardiac interventions carried out today. The low infection rate of coronary artery stents was proposed to be a result of the inflammatory nature of atherosclerosis, which may provide a protective benefit against bacterial infection of the
RI PT
stent and the overall low incidence of infection in percutaneous procedures. Stent infections are rare, with only 17 reports from 1990-2012. Subclinical infections and under-reporting may be possible reasons for such a low incidence.1
SC
The goals of the evaluation of a patient with a potential stent infection include making a clinical, radiographic and microbiologic diagnosis, detecting complications, and determining optimal therapy. Dieter et al.2 proposed criteria for the diagnosis of coronary
M AN U
stent infection. A definitive diagnosis can be made by autopsy or by examination of the surgical material. For possible diagnosis, 3 of the following criteria must be present: placement of a coronary stent within the previous 4 weeks; multiple repeat procedures performed through the same arterial sheath; the presence of bacteremia, significant fever, or leukocytosis with no other cause; acute coronary syndrome; or positive cardiac imaging. Our patient fitted into the possible diagnosis of stent infection initially, and
TE D
hence was started on antibiotic therapy.
Although positive blood cultures are diagnostic of infection, they do not identify the anatomic source of the infection. TEE, CT scan, CAG and cardiac MRI were initially
EP
proposed to make the diagnosis of stent infection and complications.1 However, these modalities identify only stent occlusion, or an abscess if present. To pinpoint the stented
AC C
segment as the source of infection, we used FDG-PET CT, which showed an abnormal FDG uptake indicating active infection or inflammation. FDG-PET CT is a proven modality in identifying occult inflammation in the body.3,4 However, patients with recent acute coronary syndrome (ACS) were found to have an increased FDG uptake within the culprit lesion.5 Differentiating stent thrombosis from stent infection on PET is extremely difficult. The diagnosis is based on the clinical scenario and other collaborative investigations. PET images in stent thrombosis suggest that in this condition, the FDG uptake is localized only to the stented region of the vessel, whereas in stent infection it is diffuse involving the surrounding soft tissue as well.
ACCEPTED MANUSCRIPT Surgery was decided for our patient as symptoms persisted with recurrent fever, positive blood culture and TEE revealing stent abscess and fistula. Stent infection, although rare, should be suspected in patients with persisting fever postPTCA. A complete evaluation with blood cultures must be carried out and adequate broad-spectrum antibiotics started. FDG-PET CT appears to be a useful modality aiding
RI PT
the diagnosis. Surgery must be considered in persistent stent infections, especially if major complications are apparent on the angiogram and/or TEE.
SC
References
1. Elieson M, Mixon T, Carpenter J. Coronary stent infections: a case report and
M AN U
literature review. Tex Heart Inst J 2012;39:884-9.
2. Dieter RS. Coronary artery stent infection. Clin Cardiol 2000;23:808-10. 3. Glaudemans AW, Signore A. FDG-PET/CT in infections: the imaging method of choice? Eur J Nucl Med Mol Imaging 2010;37:1986-91.
4. Kubota K, Nakamoto Y, Tamaki N, et al. FDG-PET for the diagnosis of fever of
TE D
unknown origin: a Japanese multi- center study. Ann Nucl Med 2011;25:355-64. 5. Cheng VY, Slomka PJ, Le Meunier L, et al. Coronary arterial 18F-FDG uptake by fusion of PET and coronary CT angiography at sites of percutaneous stenting for acute myocardial infarction and stable coronary artery disease. J Nucl Med
AC C
EP
2012;53:575-83.
Figure captions
ACCEPTED MANUSCRIPT Figure 1: Trans esophageal echocardiography image showing dilated proximal right coronary artery with stent abscess (black arrow) and vegetation on anterior tricuspid leaflet (white arrow). Figure 2: FDG-PET CT image showing abnormal FDG uptake in and around RCA stent
value (SUV) max of lesion 7.3, SUV mean 4.2).
M AN U
SC
.
RI PT
region suggestive of an active infective or inflammatory pathology (Standardized uptake
Legend for videos in Supplementary Materials
TE D
Video S1: Trans esophageal echocardiography video showing dilated proximal right coronary artery with stent abscess and vegetation on the base of anterior tricuspid leaflet. Video S2: Trans esophageal echocardiography color Doppler video showing dilated proximal right coronary artery (RCA) with stent abscess and a thin jet of continuous flow
AC C
EP
into the right atrium (RA) indicating the presence of RCA to RA fistula.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT