- Email: [email protected]
Early Onset of Acute Lower Limb Drug-eluting Stent Infection
Case Report Early Onset of Acute Lower Limb Drug-eluting Stent Infection Frederic Panthier, Edouard Warein, Frederic Cochennec, Pascal Desgranges, and Joseph Touma, Creteil, France
The present case describes acute and early infection of a superficial femoral artery drug-eluting stent (DES) in a 65-year-old patient 2 days after its implantation in outpatient clinic, with intense clinical presentation. The initial indication was Rutherford 3 peripheral artery disease. Radical treatment by means of stent explantation and femoro-femoral bypass using autogenous vein was performed. Both stent and blood cultures were positive for methicillin-sensitive Staphylococcus aureus. Informative imaging and intraoperative view are provided. Local evolution was satisfactory but endocarditis occurred secondarily. The pathophysiology of this first reported DES infection and the management of the infected vessel are discussed, in light of data derived from coronary literature and open vascular surgery.
CASE REPORT A 69-year-old man without significant comorbidities presented to our institution with Rutherford 3 peripheral artery disease recurrence. He had already been treated 3 years ago by endovascular stent implantation in the left superficial femoral artery (SFA). In-stent restenosis (ISR) was identified on a contrastenhanced computed tomography (CT) scan and managed as an outpatient procedure by adding a 6 120 mm paclitaxel-eluting stent (Zilver PTX; Cook Peripheral Vascular) partially covering the previously stented area. There were no adverse events during the procedure. No antibiotics were administered intraoperatively. Two days after, he was admitted to the emergency department with an acute onset of fever and left limb pain. Physical examination showed a warm and swollen left leg with palpable peripheral
Declarations of interest: None. Assistance Publique des H^opitaux de Paris, H^opital Henri Mondor, Service de Chirurgie Vasculaire, Creteil, France. Correspondence to: Joseph Touma, MD, Service de Chirurgie Vasculaire, H^opital Henri Mondor, 51 Avenue du Marechal de Lattre de Tassigny, 94010 Creteil, France; E-mail: [email protected] Ann Vasc Surg 2019; -: 1.e1–1.e5 https://doi.org/10.1016/j.avsg.2019.05.039 Ó 2019 Elsevier Inc. All rights reserved. Manuscript received: March 28, 2019; manuscript accepted: May 12, 2019; published online: - - -
pulses and distal vascular purpura (Fig. 1). Systemic bacterial infection was diagnosed on leukocytosis (12 109/L) and high C-reactive protein level (50 mg/L) associated with a positive blood culture for methicillin-sensitive Staphylococcus aureus (MSSA). 18Fluoro-deoxy-glucose positron emitting tomography (18FDG-PET) scan was performed and showed an increased uptake of the stent. There was no pseudoaneurysm at the puncture site. Unspecific inflammation without any leakage was observed (Fig. 2). Endocarditis was excluded via transthoracic and transesophageal echocardiogram. The initial medical treatment consisted of intravenous oxacillin and gentamicin administration. Surgical management consisted of stent and native SFA removal with in situ femoralefemoral bypass using autogenous ipsilateral reversed great saphenous vein. Parietal abscess of the SFA was observed (Fig. 3). The culture of the stent revealed positive for MSSA. The immediate postoperative course was uneventful and the patient was discharged 7 days after surgery. A total 6-week oral antibiotics was previously planned but recurrence of fever at postoperative day 10 justified patient readmission. Diagnosis of bacterial mitral endocarditis by transesophageal echocardiogram required exclusive intravenous antibiotics. Eight-week antibiotics were administered. The patient was discharged after clinical improvement and pursued his intravenous therapy in home-based hospitalization, with favorable outcome at 18 months of follow-up.
1.e1
1.e2 Case Report
Fig. 1. Distal purpura and swollen thigh observed 2 days after paclitaxel-eluted stent Zilver PTX implantation for superficial femoral artery in-stent restenosis.
DISCUSSION Drug-eluting stents (DESs) are used in treating ISR or de novo peripheral arterial occlusive disease.1 The Zilver PTX stent (Cook Medical, Bloomington, IN) is a self-expanding nitinol stent with a polymer-free paclitaxel coating. Paclitaxel elution aims to inhibit neointimal hyperplasia which is the main mechanism of restenosis. The Zilver PTX stent has shown better long-term outcomes for femoropopliteal disease compared to balloon angioplasty and provisional bare metal stent (BMS) implantation in clinical trials.2,3 Pathophysiology Early onset of peripheral stent infection, in the absence of device sterilization flaw, is thought to be related to intraoperative seeding of the stent through contamination while handling the device or through femoral puncture in the presence of chronic MSSA colonization of the patient, when inadequately prepared.4 The other predisposing factors are repetitive femoral puncture, puncture site hematoma, coexisting bacteremia, long-shaft devices, multiple ipsilateral procedures, and suboptimal environment, namely angiography suits versus operative rooms.5 In general, peripheral stent infections are extremely infrequent. So far, 26 cases of BMS have been reported, according to a relatively recent
Annals of Vascular Surgery
review of the literature.6 Specifically, the present case is the first to be reported to our knowledge, since in the same review, no DES infection was reported, justifying particular attention to paclitaxelrelated issues in terms of pathophysiology and close scrutiny of DES infection rate in the future, now that DESs are more widely used and that new coated devices are being marketed. Theoretically, it may be speculated that paclitaxel-eluting stents predispose to infection because of their immunomodulating and antiproliferative effects. DESinduced alteration of host defense mechanisms and delayed endothelialization of the stent struts might increase the susceptibility to infection. However, this supposed effect would be discussed in more delayed presentation, with respect to the present case. A parallel literature review of stent infection in coronary procedures where DESs are more commonly used, also revealed an extremely low incidence of coronary stent infection. Of 29 reported cases, 24 events were described since 2003, including 16 DESs (66%).7 Compared to coronary stents, more peripheral vascular stent infections are reported, possibly because of less harmful outcomes. To date, there is no evidence of higher or lower infection rate between coronary or peripheral vascular stents. Endothelium denudation caused by BMS induces direct contact between arterial media and metal device. It results in potential of bacteria nesting, majored when existing MSSA or methicillinresistant Staphylococcus aureus portage is associated.7 Stent re-endothelialization is therefore a crucial issue in preventing further microorganism contamination. Paclitaxel, part of the Taxanes group, represents a common cancer-killing drug used as intravenous chemotherapy, as for lung, breast, or ovarian cancer. Its effects on microtubules (polymerization) prevent mitosis, reducing granulation tissue formation up to 5 months.8 Expected effects on vascular wall consist of reduction in intimal hyperplasia and medial hypertrophy. Initially released within theoretical postoperative 72 hr, paclitaxel is sustainably spread into the different cells of arterial wall, inhibiting mitosis, in response to angioplastyrelated trauma. Compared to drug-coated balloons (DCB) and BMS, paclitaxel DES showed a significantly lower smooth muscle cell (SMC) proliferation compared to DCB and BMS (P ¼ 0.04).9 The biologic drug effect is also improved in DES implantation in terms of depth, circumference, or struts fibrin disposition. This was borne out even more by significantly lower interstrut SMC density score (P ¼ 0.004). At
Volume
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Case Report
1.e3
Fig. 2. Radiological findings: (A) absence of pseudoaneurysm at the puncture site or in-stent thrombosis (coronal and transversal view). (B) Increased uptake of the stent on 18FDG-PET scan.
low doses, the antimitotic effect of paclitaxel is not supposed to inhibit stent re-endothelialization.10 Thus, immunosuppression caused by DES has to be recalled, but is one part of multiple mechanisms.11 Clinical Presentation Peripheral vascular stent infection is a rare but highly morbid complication often occurring during the early postoperative course. Clinical findings depend on the implantation site and generally include local inflammatory symptoms associated with general signs of infections. Infectious process might locally induce arterial
thrombosis, pseudoaneurysm, or rupture. Septic embolism might also occur. In the present case, distal purpura attests of local microvascular thrombosis related to infection. More often encountered with S. aureus toxic shock syndrome, distal purpura is a red flag sign that guides to diagnosis of stent infection. Radiological Diagnosis There is no recommended imaging technique to confirm diagnosis. CT scan provides indirect signs of infection such as the presence of surrounding gas or abscess. 18FDG-PET appears as the key imaging examination showing an increased metabolism
1.e4 Case Report
Annals of Vascular Surgery
Fig. 3. Explanted paclitaxel DES and superficial femoral artery showing the parietal abscess distinct from intimal plaque, and the absence of in-stent thrombosis.
around the stent. Compared to CT-scan, PET-CT has a superior sensitivity (93% vs. 56%), specificity (70% vs. 57%), positive predictive value (82% vs. 60%), and negative predictive value (88% vs. 58%) in the field of aortic graft infections. Radiological assessment may rely on 3-dimensional visual grading and maximum standardized uptake value. These values are not specific12,13 and must be interpreted according to the clinical context. No existing data were found on PET-CT performance for peripheral stent infection despite images reports, but significant increase in SUV could be related to eluted drug, inflammation, or infection. So far there is no maximum standardized uptake value benchmark for peripheral arterial stent infection. Management According to our experience and based on existing data related to vascular stent infection, surgical treatment with complete explantation of the infected drug elution stent appears to be the appropriate management.13 There are no sufficient data comparing complete explantation with conservative treatment. In more regularly encountered vascular prosthesis infections, conservative approach is not
common, and consists of antibiotic therapy alone or antibiotics associated with additional procedures such as drainage, or surgical debridement.14 Complete explantation is often proposed when suture line is involved in the infectious process, with an anastomotic pseudoaneurysm or suture-line hemorrhage.15 Drawing a parallel with endovascular stent infections might suggest that uncomplicated stent infectionsdthat is, without local abscess, bacteremia, thrombosis, or septic embolizationd could benefit at least in fragile patients from conservative management. Two successful cases of medically managed isolated peripheral stent infection16,17 have been described. On the other hand, the risk of endocarditis and its complications justify a more radical attitude associated to intravenous antibiotics. Similar to infected vascular prosthesis, stent removal associated with in situ or extra-anatomic bypass must lie on autologous conduit use.18,19 Infected stent morbidity rate is estimated at 25% and is defined in peripheral vascular stent infection by limb amputation, colostomy (mesenteric stents), or nephrectomy (renal artery stents). Postoperative mortality rate reaches 22.5% after complete removal of the infected stent and vascular reconstruction, while mortality rate in
Volume
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endovascular treatment group (covered stent implantation or coils) is 100%. Up to 41 days of medical diagnosis delay is reported, while mean patient’s delay in recognition of health deterioration is extremely low (1.9 days).4 Intraoperative prophylactic antibiotic (PPA) treatment is recommended as soon as angioplasty is associated with stent implantation or any kind of peripheral vascular endoprosthesis,20 using unique dose of second-generation cephalosporin. Interventional Radiology Guidelines suggest PPA may be administrated in case of endovascular aortic repair or high-risk patients (peripheral vascular stent implantation).21 To date, the French Society of Anesthesiology recommends PPA for stent implantation, in peripheral or aortic location. This recommendation is not based on high level evidence and may increase emergence of antibiotic resistance. This was not performed in the present case, probably due to the outpatient conditions in a recent shift in peripheral angioplasty toward ambulatory surgery without anesthesiologic assistance. Surgeons or interventional practitioners should therefore include intraoperative antibiotherapy in their day care protocols.
CONCLUSION To our knowledge, this case reports the first peripheral arterial paclitaxel DES infection. Medical management should be associated with stent removal surgery and vascular reconstruction because of the high mortality and morbidity rates related to systemic sepsis and the risk of endocarditis. With the continuation of DES use, it will be interesting to observe whether DES implantation is associated with an increased risk of stent infection.
Case Report
5.
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8.
9.
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12.
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15.
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REFERENCES 1. Kichikawa K, Ichihashi S, Yokoi H, et al. Zilver PTX postmarket surveillance study of paclitaxel-eluting stents for treating femoropopliteal artery disease in Japan: 2-year results. Cardiovasc Intervent Radiol 2019;42:358e64. 2. Dake MD, Ansel GM, Jaff MR, et al. Paclitaxel-eluting stents show superiority to balloon angioplasty and bare metal stents in femoropopliteal disease: twelve-month Zilver PTX randomized study results. Circ Cardiovasc Interv 2011;4: 495e504. 3. Dake MD, Ansel GM, Jaff MR, et al. Sustained safety and effectiveness of paclitaxel-eluting stents for femoropopliteal lesions: 2-year follow-up from the Zilver PTX randomized and singlearm clinical studies. J Am Coll Cardiol 2013;61:2417e27. 4. Bosman WMPF, Borger van der Burg BLS, Schuttevaer HM, et al. Infections of intravascular bare metal stents: a case
18.
19. 20.
21.
1.e5
report and review of literature. Eur J Vasc Endovasc Surg 2014;47:87e99. Quintas A, Alves G, Arag~ao de Morais J, et al. Iliac artery reconstruction with femoral vein after bare metal stent infection. EJVES Short Rep 2017;34:28e31. Whitcher GH, Bertges DJ, Shukla M. Peripheral vascular stent infection: case report and review of literature. Ann Vasc Surg 2018;51:326.e9-e15. Hearn AT, James KV, Lohr JM, et al. Endovascular stent infection with delayed bacterial challenge. Am J Surg 1997;174:157e9. Wang T, Zhang J, Wang J, et al. Paclitaxel drug-eluting tracheal stent could reduce granulation tissue formation in a canine model. Chin Med J (Engl) 2016;129: 2708e13. Torii S, Yahagi K, Mori H, et al. Biologic drug effect and particulate embolization of drug-eluting stents versus drugcoated balloons in healthy swine femoropopliteal arteries. J Vasc Interv Radiol 2018;29;1041e9.e3. Scheller B, Speck U, Romeike B, et al. Contrast media as carriers for local drug delivery. Successful inhibition of neointimal proliferation in the porcine coronary stent model. Eur Heart J 2003;24:1462e7. Tzafriri AR, Edelman ER. Endovascular drug delivery and drug elution systems: first principles. Interv Cardiol Clin 2016;5:307e20. Gardet E, Addas R, Monteil J, et al. Comparison of detection of F-18 fluorodeoxyglucose positron emission tomography and 99mTc-hexamethylpropylene amine oxime labelled leukocyte scintigraphy for an aortic graft infection. Interact Cardiovasc Thorac Surg 2010;10:142e3. Argyriou C, Georgiadis GS, Lazarides MK, et al. Endograft infection after endovascular abdominal aortic aneurysm repair: a systematic review and meta-analysis. J Endovasc Ther 2017;24:688e97. Moulakakis KG, Sfyroeras GS, Mylonas SN, et al. Outcome after preservation of infected abdominal aortic endografts. J Endovasc Ther 2014;21:448e55. de Donato G, Setacci F, Galzerano G, et al. Prosthesis infection: prevention and treatment. J Cardiovasc Surg (Torino) 2014;55:779e92. Walker SR. PET CT to confirm an infected popliteal stent graft used to treat popliteal artery aneurysm. Eur J Vasc Endovasc Surg 2017;54:612. Treitl M, Rademacher A, Becker-Lienau J, et al. Successful antibiotic treatment of severe staphylococcal infection of a long stent graft in the superficial femoral artery with graft preservation in the long term. Cardiovasc Intervent Radiol 2011;34:642e6. Legout L, D’Elia PV, Sarraz-Bournet B, et al. Diagnosis and management of prosthetic vascular graft infections. Med Mal Infect 2012;42:102e9. Leroy O, Meybeck A, Sarraz-Bournet B, et al. Vascular graft infections. Curr Opin Infect Dis 2012;25:154e8. Mise a jour de la RFE Antibioprophylaxie 2017 - La SFAR [Internet]. Societe Franc¸aise d’Anesthesie et de Reanimation. Available at: https://sfar.org/mise-a-jour-de-la-rfeantibioprophylaxie-2017/; 2018. Accessed December 17, 2018. Becker GJ, Kovacs M, Mathison MN, et al. Risk stratification and outcomes of transluminal endografting for abdominal aortic aneurysm: 7-year experience and long-term followup. J Vasc Interv Radiol 2001;12:1033e46.
The present case describes acute and early infection of a superficial femoral artery drug-eluting stent (DES) in a 65-year-old patient 2 days after its implantation in outpatient clinic, with intense clinical presentation. The initial indication was Rutherford 3 peripheral artery disease. Radical treatment by means of stent explantation and femoro-femoral bypass using autogenous vein was performed. Both stent and blood cultures were positive for methicillin-sensitive Staphylococcus aureus. Informative imaging and intraoperative view are provided. Local evolution was satisfactory but endocarditis occurred secondarily. The pathophysiology of this first reported DES infection and the management of the infected vessel are discussed, in light of data derived from coronary literature and open vascular surgery.
CASE REPORT A 69-year-old man without significant comorbidities presented to our institution with Rutherford 3 peripheral artery disease recurrence. He had already been treated 3 years ago by endovascular stent implantation in the left superficial femoral artery (SFA). In-stent restenosis (ISR) was identified on a contrastenhanced computed tomography (CT) scan and managed as an outpatient procedure by adding a 6 120 mm paclitaxel-eluting stent (Zilver PTX; Cook Peripheral Vascular) partially covering the previously stented area. There were no adverse events during the procedure. No antibiotics were administered intraoperatively. Two days after, he was admitted to the emergency department with an acute onset of fever and left limb pain. Physical examination showed a warm and swollen left leg with palpable peripheral
Declarations of interest: None. Assistance Publique des H^opitaux de Paris, H^opital Henri Mondor, Service de Chirurgie Vasculaire, Creteil, France. Correspondence to: Joseph Touma, MD, Service de Chirurgie Vasculaire, H^opital Henri Mondor, 51 Avenue du Marechal de Lattre de Tassigny, 94010 Creteil, France; E-mail: [email protected] Ann Vasc Surg 2019; -: 1.e1–1.e5 https://doi.org/10.1016/j.avsg.2019.05.039 Ó 2019 Elsevier Inc. All rights reserved. Manuscript received: March 28, 2019; manuscript accepted: May 12, 2019; published online: - - -
pulses and distal vascular purpura (Fig. 1). Systemic bacterial infection was diagnosed on leukocytosis (12 109/L) and high C-reactive protein level (50 mg/L) associated with a positive blood culture for methicillin-sensitive Staphylococcus aureus (MSSA). 18Fluoro-deoxy-glucose positron emitting tomography (18FDG-PET) scan was performed and showed an increased uptake of the stent. There was no pseudoaneurysm at the puncture site. Unspecific inflammation without any leakage was observed (Fig. 2). Endocarditis was excluded via transthoracic and transesophageal echocardiogram. The initial medical treatment consisted of intravenous oxacillin and gentamicin administration. Surgical management consisted of stent and native SFA removal with in situ femoralefemoral bypass using autogenous ipsilateral reversed great saphenous vein. Parietal abscess of the SFA was observed (Fig. 3). The culture of the stent revealed positive for MSSA. The immediate postoperative course was uneventful and the patient was discharged 7 days after surgery. A total 6-week oral antibiotics was previously planned but recurrence of fever at postoperative day 10 justified patient readmission. Diagnosis of bacterial mitral endocarditis by transesophageal echocardiogram required exclusive intravenous antibiotics. Eight-week antibiotics were administered. The patient was discharged after clinical improvement and pursued his intravenous therapy in home-based hospitalization, with favorable outcome at 18 months of follow-up.
1.e1
1.e2 Case Report
Fig. 1. Distal purpura and swollen thigh observed 2 days after paclitaxel-eluted stent Zilver PTX implantation for superficial femoral artery in-stent restenosis.
DISCUSSION Drug-eluting stents (DESs) are used in treating ISR or de novo peripheral arterial occlusive disease.1 The Zilver PTX stent (Cook Medical, Bloomington, IN) is a self-expanding nitinol stent with a polymer-free paclitaxel coating. Paclitaxel elution aims to inhibit neointimal hyperplasia which is the main mechanism of restenosis. The Zilver PTX stent has shown better long-term outcomes for femoropopliteal disease compared to balloon angioplasty and provisional bare metal stent (BMS) implantation in clinical trials.2,3 Pathophysiology Early onset of peripheral stent infection, in the absence of device sterilization flaw, is thought to be related to intraoperative seeding of the stent through contamination while handling the device or through femoral puncture in the presence of chronic MSSA colonization of the patient, when inadequately prepared.4 The other predisposing factors are repetitive femoral puncture, puncture site hematoma, coexisting bacteremia, long-shaft devices, multiple ipsilateral procedures, and suboptimal environment, namely angiography suits versus operative rooms.5 In general, peripheral stent infections are extremely infrequent. So far, 26 cases of BMS have been reported, according to a relatively recent
Annals of Vascular Surgery
review of the literature.6 Specifically, the present case is the first to be reported to our knowledge, since in the same review, no DES infection was reported, justifying particular attention to paclitaxelrelated issues in terms of pathophysiology and close scrutiny of DES infection rate in the future, now that DESs are more widely used and that new coated devices are being marketed. Theoretically, it may be speculated that paclitaxel-eluting stents predispose to infection because of their immunomodulating and antiproliferative effects. DESinduced alteration of host defense mechanisms and delayed endothelialization of the stent struts might increase the susceptibility to infection. However, this supposed effect would be discussed in more delayed presentation, with respect to the present case. A parallel literature review of stent infection in coronary procedures where DESs are more commonly used, also revealed an extremely low incidence of coronary stent infection. Of 29 reported cases, 24 events were described since 2003, including 16 DESs (66%).7 Compared to coronary stents, more peripheral vascular stent infections are reported, possibly because of less harmful outcomes. To date, there is no evidence of higher or lower infection rate between coronary or peripheral vascular stents. Endothelium denudation caused by BMS induces direct contact between arterial media and metal device. It results in potential of bacteria nesting, majored when existing MSSA or methicillinresistant Staphylococcus aureus portage is associated.7 Stent re-endothelialization is therefore a crucial issue in preventing further microorganism contamination. Paclitaxel, part of the Taxanes group, represents a common cancer-killing drug used as intravenous chemotherapy, as for lung, breast, or ovarian cancer. Its effects on microtubules (polymerization) prevent mitosis, reducing granulation tissue formation up to 5 months.8 Expected effects on vascular wall consist of reduction in intimal hyperplasia and medial hypertrophy. Initially released within theoretical postoperative 72 hr, paclitaxel is sustainably spread into the different cells of arterial wall, inhibiting mitosis, in response to angioplastyrelated trauma. Compared to drug-coated balloons (DCB) and BMS, paclitaxel DES showed a significantly lower smooth muscle cell (SMC) proliferation compared to DCB and BMS (P ¼ 0.04).9 The biologic drug effect is also improved in DES implantation in terms of depth, circumference, or struts fibrin disposition. This was borne out even more by significantly lower interstrut SMC density score (P ¼ 0.004). At
Volume
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2019
Case Report
1.e3
Fig. 2. Radiological findings: (A) absence of pseudoaneurysm at the puncture site or in-stent thrombosis (coronal and transversal view). (B) Increased uptake of the stent on 18FDG-PET scan.
low doses, the antimitotic effect of paclitaxel is not supposed to inhibit stent re-endothelialization.10 Thus, immunosuppression caused by DES has to be recalled, but is one part of multiple mechanisms.11 Clinical Presentation Peripheral vascular stent infection is a rare but highly morbid complication often occurring during the early postoperative course. Clinical findings depend on the implantation site and generally include local inflammatory symptoms associated with general signs of infections. Infectious process might locally induce arterial
thrombosis, pseudoaneurysm, or rupture. Septic embolism might also occur. In the present case, distal purpura attests of local microvascular thrombosis related to infection. More often encountered with S. aureus toxic shock syndrome, distal purpura is a red flag sign that guides to diagnosis of stent infection. Radiological Diagnosis There is no recommended imaging technique to confirm diagnosis. CT scan provides indirect signs of infection such as the presence of surrounding gas or abscess. 18FDG-PET appears as the key imaging examination showing an increased metabolism
1.e4 Case Report
Annals of Vascular Surgery
Fig. 3. Explanted paclitaxel DES and superficial femoral artery showing the parietal abscess distinct from intimal plaque, and the absence of in-stent thrombosis.
around the stent. Compared to CT-scan, PET-CT has a superior sensitivity (93% vs. 56%), specificity (70% vs. 57%), positive predictive value (82% vs. 60%), and negative predictive value (88% vs. 58%) in the field of aortic graft infections. Radiological assessment may rely on 3-dimensional visual grading and maximum standardized uptake value. These values are not specific12,13 and must be interpreted according to the clinical context. No existing data were found on PET-CT performance for peripheral stent infection despite images reports, but significant increase in SUV could be related to eluted drug, inflammation, or infection. So far there is no maximum standardized uptake value benchmark for peripheral arterial stent infection. Management According to our experience and based on existing data related to vascular stent infection, surgical treatment with complete explantation of the infected drug elution stent appears to be the appropriate management.13 There are no sufficient data comparing complete explantation with conservative treatment. In more regularly encountered vascular prosthesis infections, conservative approach is not
common, and consists of antibiotic therapy alone or antibiotics associated with additional procedures such as drainage, or surgical debridement.14 Complete explantation is often proposed when suture line is involved in the infectious process, with an anastomotic pseudoaneurysm or suture-line hemorrhage.15 Drawing a parallel with endovascular stent infections might suggest that uncomplicated stent infectionsdthat is, without local abscess, bacteremia, thrombosis, or septic embolizationd could benefit at least in fragile patients from conservative management. Two successful cases of medically managed isolated peripheral stent infection16,17 have been described. On the other hand, the risk of endocarditis and its complications justify a more radical attitude associated to intravenous antibiotics. Similar to infected vascular prosthesis, stent removal associated with in situ or extra-anatomic bypass must lie on autologous conduit use.18,19 Infected stent morbidity rate is estimated at 25% and is defined in peripheral vascular stent infection by limb amputation, colostomy (mesenteric stents), or nephrectomy (renal artery stents). Postoperative mortality rate reaches 22.5% after complete removal of the infected stent and vascular reconstruction, while mortality rate in
Volume
-, -
2019
endovascular treatment group (covered stent implantation or coils) is 100%. Up to 41 days of medical diagnosis delay is reported, while mean patient’s delay in recognition of health deterioration is extremely low (1.9 days).4 Intraoperative prophylactic antibiotic (PPA) treatment is recommended as soon as angioplasty is associated with stent implantation or any kind of peripheral vascular endoprosthesis,20 using unique dose of second-generation cephalosporin. Interventional Radiology Guidelines suggest PPA may be administrated in case of endovascular aortic repair or high-risk patients (peripheral vascular stent implantation).21 To date, the French Society of Anesthesiology recommends PPA for stent implantation, in peripheral or aortic location. This recommendation is not based on high level evidence and may increase emergence of antibiotic resistance. This was not performed in the present case, probably due to the outpatient conditions in a recent shift in peripheral angioplasty toward ambulatory surgery without anesthesiologic assistance. Surgeons or interventional practitioners should therefore include intraoperative antibiotherapy in their day care protocols.
CONCLUSION To our knowledge, this case reports the first peripheral arterial paclitaxel DES infection. Medical management should be associated with stent removal surgery and vascular reconstruction because of the high mortality and morbidity rates related to systemic sepsis and the risk of endocarditis. With the continuation of DES use, it will be interesting to observe whether DES implantation is associated with an increased risk of stent infection.
Case Report
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
REFERENCES 1. Kichikawa K, Ichihashi S, Yokoi H, et al. Zilver PTX postmarket surveillance study of paclitaxel-eluting stents for treating femoropopliteal artery disease in Japan: 2-year results. Cardiovasc Intervent Radiol 2019;42:358e64. 2. Dake MD, Ansel GM, Jaff MR, et al. Paclitaxel-eluting stents show superiority to balloon angioplasty and bare metal stents in femoropopliteal disease: twelve-month Zilver PTX randomized study results. Circ Cardiovasc Interv 2011;4: 495e504. 3. Dake MD, Ansel GM, Jaff MR, et al. Sustained safety and effectiveness of paclitaxel-eluting stents for femoropopliteal lesions: 2-year follow-up from the Zilver PTX randomized and singlearm clinical studies. J Am Coll Cardiol 2013;61:2417e27. 4. Bosman WMPF, Borger van der Burg BLS, Schuttevaer HM, et al. Infections of intravascular bare metal stents: a case
18.
19. 20.
21.
1.e5
report and review of literature. Eur J Vasc Endovasc Surg 2014;47:87e99. Quintas A, Alves G, Arag~ao de Morais J, et al. Iliac artery reconstruction with femoral vein after bare metal stent infection. EJVES Short Rep 2017;34:28e31. Whitcher GH, Bertges DJ, Shukla M. Peripheral vascular stent infection: case report and review of literature. Ann Vasc Surg 2018;51:326.e9-e15. Hearn AT, James KV, Lohr JM, et al. Endovascular stent infection with delayed bacterial challenge. Am J Surg 1997;174:157e9. Wang T, Zhang J, Wang J, et al. Paclitaxel drug-eluting tracheal stent could reduce granulation tissue formation in a canine model. Chin Med J (Engl) 2016;129: 2708e13. Torii S, Yahagi K, Mori H, et al. Biologic drug effect and particulate embolization of drug-eluting stents versus drugcoated balloons in healthy swine femoropopliteal arteries. J Vasc Interv Radiol 2018;29;1041e9.e3. Scheller B, Speck U, Romeike B, et al. Contrast media as carriers for local drug delivery. Successful inhibition of neointimal proliferation in the porcine coronary stent model. Eur Heart J 2003;24:1462e7. Tzafriri AR, Edelman ER. Endovascular drug delivery and drug elution systems: first principles. Interv Cardiol Clin 2016;5:307e20. Gardet E, Addas R, Monteil J, et al. Comparison of detection of F-18 fluorodeoxyglucose positron emission tomography and 99mTc-hexamethylpropylene amine oxime labelled leukocyte scintigraphy for an aortic graft infection. Interact Cardiovasc Thorac Surg 2010;10:142e3. Argyriou C, Georgiadis GS, Lazarides MK, et al. Endograft infection after endovascular abdominal aortic aneurysm repair: a systematic review and meta-analysis. J Endovasc Ther 2017;24:688e97. Moulakakis KG, Sfyroeras GS, Mylonas SN, et al. Outcome after preservation of infected abdominal aortic endografts. J Endovasc Ther 2014;21:448e55. de Donato G, Setacci F, Galzerano G, et al. Prosthesis infection: prevention and treatment. J Cardiovasc Surg (Torino) 2014;55:779e92. Walker SR. PET CT to confirm an infected popliteal stent graft used to treat popliteal artery aneurysm. Eur J Vasc Endovasc Surg 2017;54:612. Treitl M, Rademacher A, Becker-Lienau J, et al. Successful antibiotic treatment of severe staphylococcal infection of a long stent graft in the superficial femoral artery with graft preservation in the long term. Cardiovasc Intervent Radiol 2011;34:642e6. Legout L, D’Elia PV, Sarraz-Bournet B, et al. Diagnosis and management of prosthetic vascular graft infections. Med Mal Infect 2012;42:102e9. Leroy O, Meybeck A, Sarraz-Bournet B, et al. Vascular graft infections. Curr Opin Infect Dis 2012;25:154e8. Mise a jour de la RFE Antibioprophylaxie 2017 - La SFAR [Internet]. Societe Franc¸aise d’Anesthesie et de Reanimation. Available at: https://sfar.org/mise-a-jour-de-la-rfeantibioprophylaxie-2017/; 2018. Accessed December 17, 2018. Becker GJ, Kovacs M, Mathison MN, et al. Risk stratification and outcomes of transluminal endografting for abdominal aortic aneurysm: 7-year experience and long-term followup. J Vasc Interv Radiol 2001;12:1033e46.