Conservative management of abdominal aortic stent-graft infection.

Transcription

1 Conservative management of abdominal aortic stent-graft infection. Poster No.: C-0702 Congress: ECR 2015 Type: Scientific Exhibit Authors: D. Uceda, E. Lonjedo, E. Casula, S. P. G. Alandete, M. A. Meseguer, E. De la Via; Valencia/ES Keywords: Infection, Abscess, Treatment effects, Puncture, Abscess delineation, PET-CT, CT, Interventional vascular, Arteries / Aorta, Abdomen DOI: /ecr2015/C-0702 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 18

2 Aims and objectives The treatment of abdominal aortic aneurism, availability and durability of stent-graft materials has revolutionized the management of patients with abdominal aortic stentgraft infection. This technique is not free of complications and the infection is the most dreaded. Our purpose is to describe our experience in the conservative management of abdominal aortic stent-graft infection, the imaging findings after treatmen and a litetature review. Methods and materials Prospective, evolutionary and surveillance study of conservative management of stentgraft infections in four patients. Diagnosis was based on clinical, microbiology parameters and image studies. Conservative management included: Fine needle aspiration puncture (FNAP) with or without percutaneous drainage with urokinase infusion and intravenous antibiotic therapy without stent-graf removal. We value the presence of aorto-enteric fistula, concomitant infection, time from stent placement and associated treatments. Results Patient 1: 64 year-old patient with vascular risk factors (hypertension, dyslipidemia and smoking habits) and abdominal aortic aneurysm excluded by stent-graft in May 2013 requieres medical attention for bilateral inguinal pain, malaise and myalgia. CT performed revealed signs of infected abdominal aortic aneurysm (endoluminal air bubbles, reactive lymphadenopathy and subtle periaortic fat stranding). PET-CT showed focal captation area over left psoas (fig.1). A conservative management with antibiotic therapy was implanted and clinic and analytic parameters improved during the hospital stay. However, a few days later, his clinical status got worse and a new CT scan revealed progression in the size of the aneurysms and involvement of the left psoas (fig.2). Page 2 of 18

3 In view of this situation, an ultrasound guided puncture and catheter drainage placement were performed over the left psoas abscess. CT control scan revealed decreasing size of the abscess (fig.3). Same attitude was adopted with the aortic aneurysm; a 8.5F catheter was placed into it with the patient on prone position and 200 cc of purulent material was drained (fig.4). The patient outcome was satisfactory and posterior CT studies showed marked decrease in the aneurysm sac size (fig.5 and fig.6). Patient 2: 80 year-old patient with hypertension, ischemic cardiomyopathy and smoking habits, is diagnosed of abdominal aortic aneurysm in April 2013 on CT performed in clinical context of back pain. Aneurysm exclusion by EVAR is performed on May 3, Three months later the patient suffered nightly abdominal pain and fever. CT revealed a larger aneurysmal sac with thickened aortic wall and small peripheral abscesses with hypermetabolic activity on PET-CT (fig.7). This patient underwent an echocardiography study with final diagnosis of infective endocarditis; antibiotic therapy was established, with consequent clinical and analytical improvement. CT performed a month later revealed aneurysmal sac enlargement and increasing peripheral collections with extension to the left psoas (fig.8). In this context, a direct punction of the aneurismatic sac was performed and a percutaneous catheter drainage was placed by interventional radiology; 30 cc of hematic exudate was obtained during the procedure and 220 cc after two days (Fig.9, images above). Despite of the drainage, CT performed a few days later showed no morphological changes on the aneurysm size (Fig.9, images below), and thus, an Urokinase therapy was established along three consecutive sessions; with this treatment 400 cc of exudative marerial was drained. There was important clinic and analytic parameters improvement and the patient was discharge from the hospital (Fig.10). Patient 3: Page 3 of 18

4 76 year-old patient with atrial flutter, chronic renal failure on dialysis and abdominal aortic aneurysm excluded by stent-graft in May The patient presented fever without a source in December CT revealed important infra-renal abdominal aortic aneurysm (máximum diameter of 75 mm) with thickened aortic wall, findings highly suggestives of infection (Fig.11). This patient underwent antibiotic therapy with significative improvement and additional interventional procedures were not considered (Fig.12 and Fig.13). Currently, the patient is clinically stable. Patient 4: 71 year-old patient is admitted to hospital in 2010 because of epigastric pain and upper gastrointestinal (GI) bleeding. Upper GI endoscope was performed and active bleeding was identified. Urgent CT (Fig.14, images above) revealed an infrarrenal aneurysm (45 mm of diameter) and indirect signs of aortoenteric fistula. The aneurysm was excluded by EVAR (Fig.14, images below) and the patient was admitted to the intensive care unit under antibiotic therapy. Despite of an initial improvement, the patient clinically got worse and new CT scan was performed (Fig.15). A fine needle aspiration puncture was nondiagnostic and the patient continued with antibiotic treatment (Fig.16) with clinical improvement since then. Summary: Four patients were diagnosed of stent-graft infection. Two of them received antibiotic therapy after the diagnosis with blood cultures and FNAP of the aneurysm sac. Two other men were at high risk because of early endograft infection and aorto-enteric fistula. The first one was treated by placing a catheter drainage, instillation of diluted urokinasa and heparin in three sessions. On the other one, we performed FNAP with a drainage catheter emplacement. Both aneurismatic sacs decreased in size and the patients continued with antibiotics. All patients improved their clinical parameters and clinically. Images for this section: Page 4 of 18

5 Fig. 1 Fig. 2 Page 5 of 18

6 Fig. 3 Page 6 of 18

7 Fig. 4 Fig. 5 Page 7 of 18

8 Fig. 6 Page 8 of 18

9 Fig. 7: 80 year-old patient with cardiovascular risks factors and abdominal aortic aneurysm excluded by stent-graft. CT performed in order to study inespecific back pain, fever and leukocytosis. Page 9 of 18

10 Fig. 8: CT after one month of antibiotic therapy reveals radiologic worsening with aneurysmal sac enlargement and increasing peripheral collections which extend to left psoas. Page 10 of 18

11 Fig. 9: Images above: Direct punction of the aneurismatic sac and percutaneous drainage were performed by interventional radiology. Images below: Despite of the drainage, CT performed a few days later showed no morphological changes on the aneurysm size, and thus, an Urokinase therapy was established Page 11 of 18

12 Fig. 10: Significant radiological improvement in the last control performed about 5 months after urokinase therapy and percutaneous drainage. Page 12 of 18

13 Fig. 11: CT-scan shows an important infra-renal abdominal aortic aneurysm with aortic wall thickening with máximum diameter of 75 mm. Fig. 12: Significative improvement anfter antibiotic therapy. Additional procedures were not considered. Page 13 of 18

14 Fig. 13: Significative improvement anfter antibiotic therapy. Additional procedures were not considered. Page 14 of 18

15 Fig. 14: Infrarrenal aneurysm (45 mm of diameter) and indirect signs of aortoenteric fistula (no showed) Page 15 of 18

16 Fig. 15: Periaortic slightly signs of infection at level of aortoiliac bifurcation. Page 16 of 18

17 Fig. 16: Signs of stent-graft infection and type I endoleak. Page 17 of 18

18 Conclusion Conservative management of abdominal aortic stent-graft infection seems to be effective and should be considered in hemodynamically stable patients with proper graft function in order to avoid a potential surgery which, based on literature, has high rates of mortality. Personal information References The relevance of aortic endograft prosthetic infection. (J Vasc Surg 2011;54:327-33). Prosthetic stent graft infection after endovascular abdominal aortic aneurysm repair. (J Vasc Surg 2007;46:442-8). Antibiotics and Drainage for Treating Stent-Graft Infection after EVAR. Ann Vasc Dis Vol.5, No.4; 2012; pp Treatment strategies and outcomes in patients with infected aortic endografts.(j Vasc Surg 2013;58:371-9.).Clinical Practice Guidelines for Endovascular Abdominal Aortic Aneurysm Repair: Written by the Standards of Practice Committee for the Society of Interventional Radiology and Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Interventional Radiology Association. J Vasc Interv Radiol 2010;21: The management of endograft infections following endovascular thoracic and abdominal aneurysm repair. (J Vasc Surg 2013;58: ) Secondary Infections of Thoracic and Abdominal Aortic Endografts. (J Vasc Interv Radiol 2009;20: ). Antibiotics and Drainage for Treating Stent-Graft Infection after EVAR. Ann Vasc Dis Vol.5, No.4; 2012; pp Complications after Endovascular Aneurysm Repair. SEMINARS IN INTERVENTIONAL RADIOLOGY/VOLUME 26, NUMBER Page 18 of 18