Peripheral Vascular Stent Infections PVSIs

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Peripheral vascular stenting in combination with percutaneous angioplasty procedures has been the most common nonsurgical treatment of atherosclerosis in recent years, accounting for more than 400,000 implantations per year in the USA. The risk of infection is reported as being lower than 1 case per 10,000 procedures [65].

Vascular Stent With Spiral Stent Struts

Fig. 14.1.2 Axial spiral CT slice in a patient with infected bifurcated aortofemoral graft during the arterial phase post iv contrast administration. A fluid collection with enhancing wall (black arrows) is shown medially to the left iliopsoas muscle. Inside this fluid collection a part of the occluded infected graft (black arrowhead) is demonstrated. The occluded, calcified, native external iliac artery is recognized medially to the fluid collection. The right leg of the graft is patent (white stroke arrowhead)

Fig. 14.1.2 Axial spiral CT slice in a patient with infected bifurcated aortofemoral graft during the arterial phase post iv contrast administration. A fluid collection with enhancing wall (black arrows) is shown medially to the left iliopsoas muscle. Inside this fluid collection a part of the occluded infected graft (black arrowhead) is demonstrated. The occluded, calcified, native external iliac artery is recognized medially to the fluid collection. The right leg of the graft is patent (white stroke arrowhead)

The purported risk factors are:

• Prolonged use of an indwelling catheter or sheath and reuse beyond 24 h postoperatively, especially in patients receiving thrombolytic therapy.

• Repetitive use of the same femoral artery as vascular access within the first week of the stenting procedure.

• Haematoma formation.

• Increased procedural time.

• Multiple surgical interventions on the same vessel or adjacent sites.

The iliac artery is the most commonly affected vessel, accounting for 50% of the total cases of infections reported after peripheral vascular stenting. Clinical signs usually develop within 1 month of stent deployment, a fact that underscores the peri-operative or directly postoperative mechanism of bacterial inoculation of the implant. Clinical picture includes fever and sepsis in the majority of cases, whereas local signs such as pain and oedema are also common [53].

In PVSIs, S. aureus typically predominates in early as well as in late infections, accounting for 83% of total reported infections being recovered from blood cultures and operative fluid specimens [3, 31]. In late PVSIs caused by S. aureus, haematogenous seeding of the stent is more probable. Groin incision, which is the commonest vascular access for stenting, and lack of chemoprophylaxis in the early years of stenting procedures are probably the cause of the overrepresentation of this pathogen in PVSIs [1]. CT scanning has a sensitivity that exceeds 90% in detecting PVSIs, especially by use of serial imaging. Primary prophylaxis for stent placement was not initially advocat

Peripheral Vein Stent

Fig. 14.1.3 Axial arterial phase spiral CT slice in a patient with bifurcated aortofemoral graft, thrombosis of the right graft leg and an occluded femoro-femoral graft. On the left at the site of the femoro-femoral anastomosis there is a fluid collection with enhancing wall (black arrow). Inside the collection the lumen of the graft is patent (black stroked arrowhead). The occluded femoro-femoral graft (black arrowheads) is demonstrated coursing transversely in the subcutaneous tissues

Fig. 14.1.3 Axial arterial phase spiral CT slice in a patient with bifurcated aortofemoral graft, thrombosis of the right graft leg and an occluded femoro-femoral graft. On the left at the site of the femoro-femoral anastomosis there is a fluid collection with enhancing wall (black arrow). Inside the collection the lumen of the graft is patent (black stroked arrowhead). The occluded femoro-femoral graft (black arrowheads) is demonstrated coursing transversely in the subcutaneous tissues ed due to the extremely low risk of infection. Nevertheless, after identification of risk factors, there is an increasing belief that administration of primary prophylaxis, as recommended for graft implantation, is reasonable [31]. After the adoption of primary antimicrobial prophylaxis in vascular stenting, the prevalence of S. aureus in PVSIs has diminished, compared to older studies [39,41]. Studies in animal models have proven the formation of pseu-dointima during stent incorporation to the vessel wall, which may be protective against bacterial invasion, thus rendering the need for secondary prophylaxis unjustified beyond the early postoperative period. In addition, dental, genitourinary, respiratory and gastrointestinal procedures have not been implicated in the mechanism of

PVSIs. Secondary prophylaxis is indicated when drainage of a remote purulent collection is performed, or before subsequent surgical manipulations in a stented vessel or surrounding tissues [16, 31, 50, 72].

Despite their rarity, PVSIs are associated with significant mortality and morbidity. The most common complications are: multiple organ dysfunction syndrome, adult respiratory distress syndrome, disseminated intravascu-lar coagulation, osteomyelitis and amputation of the distal extremity due to embolization, vessel rupture or prolonged hypotension in the context of systemic sepsis [3, 6, 7,17, 73, 76]. The diagnosis requires a high grade of clinical suspicion in patients with prior endovascular stent placement presenting with local and systemic signs of in fection. Blood and tissue/pus cultures should be obtained and empiric antibiotic treatment against S. aureus should be initiated. Management of PVSIs includes total excision of the stent and the vessel, along with extensive perivascular debridement of the infected tissues, extra-anatomic revascularization of the affected site and appropriate antimicrobial treatment. The duration of treatment depends upon the surgeon's expertise. Emphasis should be given to the identification of the infecting pathogen, before antibiotic treatment onset, in order to optimize antimicrobial treatment. Most experts recommend a treatment duration no shorter than 6 weeks, as described in the general part of this chapter. In patients with comorbidities who cannot tolerate surgical treatment, long-term suppressive antimicrobial treatment is a reasonable approach with acceptable results [31].

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