Limits...
A case of stent graft infection coupled with aorto-esophageal fistula following thoracic endovascular aortic repair in a complex patient.

Lee SH, Song PS, Kim WS, Park KB, Choi SH - Korean Circ J (2012)

Bottom Line: Three months after stent-grafting, she experienced back pain.CT and PET imaging suggested a PGI.The patient underwent surgical treatment for PGI with AEF.

View Article: PubMed Central - PubMed

Affiliation: Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

ABSTRACT
The incidence of peri-stent graft infection (PGI) following thoracic endovascular aortic repair (TEVAR) is low, but the associated mortality rates are extremely high. The diagnosis of this complication can be difficult due to nonspecific symptoms. Here, we report a case of PGI combined with an aorto-esophageal fistula (AEF) diagnosed by computed tomography (CT) and positron emission tomography (PET) imaging after TEVAR. A 50-year-old woman with a history of diabetes mellitus and chronic hemodialysis had received a stent graft for a contained rupture of a pseudoaneurysm of the descending thoracic aorta. Three months after stent-grafting, she experienced back pain. CT and PET imaging suggested a PGI. The patient underwent surgical treatment for PGI with AEF.

No MeSH data available.


Related in: MedlinePlus

CT scan reveals the stent graft surrounded by soft tissue with air bubbles in the descending thoracic aorta (A). Positron emission tomography scan shows increased segmental fluorodeoxyglucose uptake, mostly at sites of abnormal CT findings (B and C), increasing the likelihood of these findings representing peri-stent graft infection.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC3369972&req=5

Figure 2: CT scan reveals the stent graft surrounded by soft tissue with air bubbles in the descending thoracic aorta (A). Positron emission tomography scan shows increased segmental fluorodeoxyglucose uptake, mostly at sites of abnormal CT findings (B and C), increasing the likelihood of these findings representing peri-stent graft infection.

Mentions: A 50-year-old woman was admitted to the emergency room with back pain, nausea and mild fever for longer than 7 days. Three months prior, she had undergone stent graft implantation with a 28-100 mm SEAL stent graft (S&G, Seoul, Korea) for emergent treatment of a contained rupture of a pseudoaneurysm of the descending thoracic aorta (Fig. 1). The patient had a past history of diabetes mellitus for 20 years and had been on hemodialysis for 16 years. Two months prior, her right leg was amputated below the knee secondary to diabetic foot gangrene. On admission, her temperature was 37.8℃. Laboratory findings were as follows: leukocyte count of 11.47×103/µL with 79.6% neutrophils, hemoglobin of 10.3 g/dL, platelet count of 287×103/µL, erythrocyte sedimentation rate of 120 mm/hr and C-reactive protein (CRP) of 2.29 mg/dL. CT imaging showed the stent graft surrounded by soft tissue and air bubbles in the descending thoracic aorta compared to a previous, immediate post-operative examination (Fig. 2). PGI was suspected based on CT findings. Empirical intravenous vancomycin and tazocin were initiated after obtaining blood cultures but the blood cultures yielded no growth. PET imaging was performed to quantify inflammatory activity and assess the extent of infection. This was notable for increased focal segmental fluorodeoxy-glucose (FDG) uptake around the mid to distal portions of the stent in the descending thoracic aorta (Fig. 2). Although aggressive antibiotic therapy was administered, a mild fever continued. CRP increased from 2.29 to 5.01 mg/dL, and hemoglobin decreased from 10.3 to 8.4 g/dL. Despite the high risk of mortality for performing an operation due to the patient's poor general condition, we decided to perform the surgical removal and aorta repair. A large amount of melena (1.5 L) was passed during induction of general anesthesia. Esophago-gastro-duodenoscopy revealed a 1 cm diameter outpouching in the mid-esophagus which was covered with clotted blood (Fig. 3). Surgical exploration revealed pus-like discharge around the stent graft, with an AEF at the mid third of the esophagus. The infected stent graft was removed and replaced with a Rifampicin-soaked 24 mm Gelweave graft (Terumo, Tokyo, Japan) with primary closure of the AEF. Aorta and vascular graft specimens demonstrated no microorganisms on Gram staining. Despite appropriate intensive care, she died of intractable shock and respiratory failure 9 days after the operation.


A case of stent graft infection coupled with aorto-esophageal fistula following thoracic endovascular aortic repair in a complex patient.

Lee SH, Song PS, Kim WS, Park KB, Choi SH - Korean Circ J (2012)

CT scan reveals the stent graft surrounded by soft tissue with air bubbles in the descending thoracic aorta (A). Positron emission tomography scan shows increased segmental fluorodeoxyglucose uptake, mostly at sites of abnormal CT findings (B and C), increasing the likelihood of these findings representing peri-stent graft infection.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3369972&req=5

Figure 2: CT scan reveals the stent graft surrounded by soft tissue with air bubbles in the descending thoracic aorta (A). Positron emission tomography scan shows increased segmental fluorodeoxyglucose uptake, mostly at sites of abnormal CT findings (B and C), increasing the likelihood of these findings representing peri-stent graft infection.
Mentions: A 50-year-old woman was admitted to the emergency room with back pain, nausea and mild fever for longer than 7 days. Three months prior, she had undergone stent graft implantation with a 28-100 mm SEAL stent graft (S&G, Seoul, Korea) for emergent treatment of a contained rupture of a pseudoaneurysm of the descending thoracic aorta (Fig. 1). The patient had a past history of diabetes mellitus for 20 years and had been on hemodialysis for 16 years. Two months prior, her right leg was amputated below the knee secondary to diabetic foot gangrene. On admission, her temperature was 37.8℃. Laboratory findings were as follows: leukocyte count of 11.47×103/µL with 79.6% neutrophils, hemoglobin of 10.3 g/dL, platelet count of 287×103/µL, erythrocyte sedimentation rate of 120 mm/hr and C-reactive protein (CRP) of 2.29 mg/dL. CT imaging showed the stent graft surrounded by soft tissue and air bubbles in the descending thoracic aorta compared to a previous, immediate post-operative examination (Fig. 2). PGI was suspected based on CT findings. Empirical intravenous vancomycin and tazocin were initiated after obtaining blood cultures but the blood cultures yielded no growth. PET imaging was performed to quantify inflammatory activity and assess the extent of infection. This was notable for increased focal segmental fluorodeoxy-glucose (FDG) uptake around the mid to distal portions of the stent in the descending thoracic aorta (Fig. 2). Although aggressive antibiotic therapy was administered, a mild fever continued. CRP increased from 2.29 to 5.01 mg/dL, and hemoglobin decreased from 10.3 to 8.4 g/dL. Despite the high risk of mortality for performing an operation due to the patient's poor general condition, we decided to perform the surgical removal and aorta repair. A large amount of melena (1.5 L) was passed during induction of general anesthesia. Esophago-gastro-duodenoscopy revealed a 1 cm diameter outpouching in the mid-esophagus which was covered with clotted blood (Fig. 3). Surgical exploration revealed pus-like discharge around the stent graft, with an AEF at the mid third of the esophagus. The infected stent graft was removed and replaced with a Rifampicin-soaked 24 mm Gelweave graft (Terumo, Tokyo, Japan) with primary closure of the AEF. Aorta and vascular graft specimens demonstrated no microorganisms on Gram staining. Despite appropriate intensive care, she died of intractable shock and respiratory failure 9 days after the operation.

Bottom Line: Three months after stent-grafting, she experienced back pain.CT and PET imaging suggested a PGI.The patient underwent surgical treatment for PGI with AEF.

View Article: PubMed Central - PubMed

Affiliation: Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

ABSTRACT
The incidence of peri-stent graft infection (PGI) following thoracic endovascular aortic repair (TEVAR) is low, but the associated mortality rates are extremely high. The diagnosis of this complication can be difficult due to nonspecific symptoms. Here, we report a case of PGI combined with an aorto-esophageal fistula (AEF) diagnosed by computed tomography (CT) and positron emission tomography (PET) imaging after TEVAR. A 50-year-old woman with a history of diabetes mellitus and chronic hemodialysis had received a stent graft for a contained rupture of a pseudoaneurysm of the descending thoracic aorta. Three months after stent-grafting, she experienced back pain. CT and PET imaging suggested a PGI. The patient underwent surgical treatment for PGI with AEF.

No MeSH data available.


Related in: MedlinePlus