Antibiotics and Percutaneous Drainage for

Treating Stent-Graft Infection After EVAR

Feng Zhu, Xiaohu Ge, Hongbo Ci, and Sheng Guan, Urumqi, China

Artificial graft infection is one of the most serious complications following EVAR. The gold
standard includes the excision of the infected endograft, debridement, and reconstruction.
However, these methods are not always the best option for every patient. The authors pre-
sent the case of a 75-year-old man who was diagnosed with a stent-graft infection following
EVAR. A course of antibiotics was administered, and percutaneous drainage was effectively
performed twice in succession. After 18 months, the patient was admitted again due to the
infection re-occurring. Antibiotics were administered, and percutaneous drainage was effec-
tively re-performed. One year has elapsed since the treatment, and the outpatient followup
has lasted until now.

INTRODUCTION of stent-graft infection following EVAR and docu-

mented complete clinical data over a 3-year period.
Endovascular aneurysm repair (EVAR) of abdominal The patient consented to the publication of this
aortic aneurysms (AAA) has undergone explosive report.
growth over the last 2 decades. EVAR reduces com-
plications and perioperative mortality. But it also cre-
ates new problems, such as endoleaks, iliac branch CASE REPORT
occlusion, spinal cord ischemia, and so on. Artificial
graft infection is one of the most serious complica- A 75-year-old man experienced intermittent dizziness for
tions following EVAR, with mortality rates ranging more than five months. His past history included ischemic
from 25 to 75%.1 The incidence is about 0.3e2%.2 heart disease, hypertension, and ischemic cerebrovascular
The gold standard for artificial graft infection in- disease.
Clinical examinations showed a lower abdominal pul-
cludes the excision of the infected endograft,
satile mass. By performing computed tomography angiog-
debridement, and reconstruction.3 However, these raphy (CTA), we further confirmed the presence of an
methods are not always the best option for every pa- abdominal aortic aneurysm, the diameter of which was
tient. We provide an early experience report on the 70 mm, with a neck longer than 15 mm. The right com-
administration of antibiotics and percutaneous mon iliac artery was also aneurysmal (Fig. 1A).
drainage that was re-performed for the treatment EVAR procedure was proposed and performed by a
vascular surgeon in the angiography suite. We per-
formed percutaneous EVAR with the patient under gen-
eral anesthesia. An abdominal aortic angiogram revealed
local distortion and dilatation of the middle and lower
Department of Vascular Surgery, People’s Hospital of Xinjiang
Uygur Autonomous Region, Urumqi, China. segments of the abdominal aorta (below the initial
Correspondence to: Feng Zhu, Department of Vascular surgery, Peo- segment of the bilateral renal arteries). The lesions
ple’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi, 830000 affected the bilateral iliac arteries and were more serious
China; E-mail: [email protected] on the right side. The maximum diameter of the aortic
Ann Vasc Surg 2020; 65: 289.e1–289.e6 aneurysm was approximately 70 mm. The intima of
https://doi.org/10.1016/j.avsg.2019.12.009 the abdominal aorta was not smooth, and mural thrombi
Ó 2019 The Authors. Published by Elsevier Inc. This is an open access could be seen in the lumen. The morphology of the
article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
bilateral renal arteries, celiac artery, and superior mesen-
Manuscript received: September 26, 2019; manuscript accepted: teric artery were normal. An Endurant Stent Graft Sys-
December 5, 2019; published online: 19 December 2019 tem of the aortic-iliac bifurcated component

289.e1
289.e2 Case reports Annals of Vascular Surgery

Fig. 1. (A) An abdominal aortic aneurysm and a right iliac angiography. (B) Digital subtraction angiography clearly
aneurysm (arrows) were observed on 3D-CTA. 3D- shows that the abdominal aortic aneurysm and iliac aneu-
CTA ¼ three-dimensional computed tomography rysm were completely isolated.

(ENBF2816C170EE, Medtronic, Minneapolis, MN) was punctured point was found and sutured, hemostasis was
passed through the abdominal aorta to completely block performed, and the incision closed.
the aneurysm, by inserting percutaneously via the left The patient had intermittent low fever after the second
common femoral artery. Two Endurant Stent Graft Sys- operation. Blood test results were as follows: peripheral
tems of iliac extension (ENLW1616C120EE, Medtronic, white blood cells 12.57
109/L, C-reactive protein
Minneapolis, MN) were placed successively at the left 89.20 mg/L, erythrocyte sedimentation rate 24 mm/h, pro-
iliac artery distal end. An Endurant Stent Graft System calcitonin 9.33 ng/mL, blood urea nitrogen 9.40 mmol/L,
of aorto-uni-iliac stent graft (ENLW1613C120EE, Med- creatinine 88.50 mmoI/L, systolic pressure:135e150 mm
tronic, Minneapolis, MN) and an Endurant Stent Graft Hg, diastolic pressure: 70e100 mm Hg, blood cultures
System of iliac extension (ENLW1616C120EE, Med- were negative. Pulmonary computed tomography (CT)
tronic, Minneapolis, MN) were placed successively at revealed a slight exudation in the lower left lung. This
the right iliac artery distal end, by inserting percutane- was considered as pneumonia. For tackling this persistent
ously via the right common femoral artery. A postoper- infection, the treatment plan was intravenous antibiotics,
ative angiogram confirmed a complete closure of the 3 g of Cefoperazone Sulbactam +100 mL of saline, q12 h.
aneurysm cavity (Fig. 1B). Antibiotics were administered for 10 days, and leukocyte
On postoperative day three, the patient had subcutane- count, C-reactive protein, erythrocyte sedimentation
ous hematoma at the punctured point of the right groin, rate, and procalcitonin returned to normal levels when
and swelling of the right lower extremity. The symptoms the patient was discharged. The results of three consecutive
did not improve after local pressure. Emergency ‘‘right blood cultures were negative.
femoral artery exploration’’ was carried out under local After 20 days, the patient was admitted again due to
anesthesia: the subcutaneous tissues were separated layer 10 days of lumbar and abdominal pain and high fever.
by layer, the proximal segment of the superficial femoral The CT revealed right hydronephrosis (Fig. 2A) and right
artery was exposed and blocked, the entry tear at the groin subcutaneous soft tissue infection (Fig. 2B).
Volume 65, May 2020 Case reports 289.e3

Fig. 2. (A and B): After 20 days, the patient was admitted shadows around the stent and bubble shadows (D). (E) Af-
again due to 10 days of lumbar and abdominal pain and ter one month of treatment, CT revealed that the lesion
high fever. Arrows indicate the right hydronephrosis (A) had not significantly shrunk. (F) At three months after
and the right groin subcutaneous soft tissue infection (B) treatment, the symptoms of high fever and low back
on plain CT. (C and D): At one month after antiinflamma- pain were relieved. Arrows indicated that the lesion had
tory treatment, CT revealed an abscess of the left greater significantly shrunk.
psoas muscle (C), and arrows indicate mixed density

Peripheral white blood cells 8.14
109/L, C-reactive pro- tests, we suspected this to be a case of artificial graft infec-
tein 29.60 mg/L, blood urea nitrogen 6.60 mmol/L, creat- tion after EVAR.
inine 66.80 mmoI/L, systolic pressure: 120e145 mm Hg, The patient was old and had many underlying diseases.
diastolic pressure: 70e85 mm Hg. The blood culture re- In addition, the patient’s family members refused an open
sults were negative. The diagnosis was as follows: (1) bilat- operation: artificial graft resection + revascularization was
eral hydronephrosis; (2) right groin subcutaneous performed. According to the opinion of the patient’s fam-
infection. The treatment plan was intravenous antibiotics, ily members, the patient underwent conservative treat-
0.5 g of levofloxacin +100 mL of saline, q24 h. ment: systemic antiinflammatory + ultrasound-guided
At one month after antiinflammatory treatment, the drainage was performed. The patient underwent
symptom of high fever of the patient was not significantly ultrasound-guided drainage; the process is as follows:
alleviated, and the lumbar and abdominal pains turned the patient was placed in the right lateral position, routine
into left back pain. A reexamination was performed. CT disinfection was performed, and surgical drapes were
revealed an abscess of the left greater psoas muscle placed. Puncture points were located by B ultrasound:
(Fig. 2C), and mixed density shadows around the stent one puncture point was located at the left waist, and the
and bubble shadows (Fig. 2D). The results of the blood cul- target puncture area was a retroperitoneal purulent cav-
ture indicated Escherichia coli. Based on the clinical mani- ity. The other one puncture point was located at the left
festations, physical signs, and results of biochemical ilium waist, and the target puncture area was the left iliac
289.e4 Case reports Annals of Vascular Surgery

Fig. 3. (A) After 18 months, the patient was admitted muscle (arrow). (B) After one month of treatment, a
again due to lumbar pain and fever. The CT revealed reexamination was performed, and the CT revealed that
the recurrence of an abscess of the left greater psoas the lesion had significantly shrunk (arrow).

fossa. After successful local anesthesia, under the guid- the punctured tube was fixed and connected to the
ance of B ultrasound, a 16F (Bard, Navarre, Universal drainage bag. After the operation, the lesion cavity was
Drainage Catheter with Nitinol) puncture needle was washed intermittently with 100 mL of diluted iodophor
used to enter the left waist. After the puncture needle (0.06e1%) and 500,000 units of polymyxin B irrigant
had entered the retroperitoneal purulent cavity, the nee- (Polymyxin B Sulfate Powder 0.5MU, Pfizer) + 30 mL of
dle core was pulled out, and the punctured tube was fixed normal saline (0.9%). In addition, the patient was treated
and connected to the drainage bag. After successful local with systemic antiinflammation, according to the results
anesthesia, under the guidance of B ultrasound, a 10F of the drug sensitivity test, which included antibacterial
(Bard, Navarre, Universal Drainage Catheter with Nitinol) drugs (meropenem, daptomycin, faropenem, levofloxa-
puncture needle was used to enter the left ilium waist. Af- cin, minocycline, and tigecycline) and antifungal drugs
ter the puncture needle had entered the left iliac fossa pu- (fluconazole and voriconazole).
rulent cavity, the needle core was pulled out, and the At three months after treatment, the symptoms of fever
punctured tube was fixed and connected to the drainage and low back pain of the patient were relieved. A reexami-
bag. The wound was washed intermittently with normal nation was performed, and the CT revealed that the lesion
saline after the operation. had significantly shrunk (Fig. 2F), peripheral white blood
After one month of treatment, the patient continued to cells 5.69
109/L, C-reactive protein32.33 mg/L, blood
have an intermittent fever. Peripheral white blood cells urea nitrogen 7.00 mmol/L, creatinine 90.90 mmoI/L, sys-
15.63
109/L, C-reactive protein 235 mg/L, blood urea tolic pressure: 115e131 mm Hg, diastolic pressure: 70e
nitrogen 8.20 mmol/L, creatinine 97.20 mmoI/L, systolic 83 mm Hg, blood cultures were negative. The patient contin-
pressure: 121e148 mm Hg, diastolic pressure: 62e uously orally received meropenem for antiinflammation.
89 mm Hg, blood cultures were positive. Hence, a reex- After 18 months, the patient was admitted again due to
amination was performed. The CT revealed that the lesion lumbar pain and fever. The CT revealed the recurrence of
did not significantly shrink (Fig. 2E). We decided to an abscess of the left greater psoas muscle (Fig. 3A). Pe-
perform puncture and drain again. After general anes- ripheral white blood cells 9.65
109/L,C-reactive protein
thesia, a laparoscope and an ultrasound probe were used 99.57 mg/L, blood urea nitrogen 6.46 mmol/L, creatinine
to determine the location of the lesion. The process is as 93.60 mmoI/L, systolic pressure: 103e144 mm Hg, dia-
follows: the patient was placed in the supine position. Af- stolic pressure: 54e80 mm Hg. The results of the blood
ter general anesthesia, routine disinfection was per- culture indicated Escherichia coli. The treatment plan was
formed, and surgical drapes were placed. intravenous antibiotics,1 g of meropenem +100 mL of sa-
Pneumoperitoneum was established, and the retroperito- line, q8h. The family members of the patient continued to
neum was dissected under a laparoscope. At this time, opt for conservative treatment. We decided to perform
dilatation of the abdominal aorta and bilateral iliac arteries puncture and drain again. After intravenous anesthesia,
could be seen. The left iliolumbar region was explored a laparoscope and an ultrasound probe were used to deter-
with a laparoscopic ultrasound probe, and a low-density mine the location of the lesion. Under B-ultrasound-guid-
mixed mass around the left common iliac artery was ance, the fossa of the left greater psoas muscle was
seen. Under the guidance of ultrasound, a 10F (Bard, Nav- punctured with a 10F puncture needle (Bard, Navarre,
arre, Universal Drainage Catheter with Nitinol) puncture Universal Drainage Catheter with Nitinol), and catheteri-
needle was used to puncture the mass. The drained fluid zation and fixation were given. After the operation, the
was a yellow purulent secretion. A sample was taken for lesion cavity was washed intermittently with 100 mL of
biological detection. The needle core was pulled out, and diluted iodophor water (0.06%). According to the results
Volume 65, May 2020 Case reports 289.e5

of the drug sensitivity test, the patient was treated with destructive enzymes to the lesions, and relieve sys-
faropenem for systemic antiinflammation. temic symptoms, such as fever and pain.9,10 Shu-
After one month of treatment, the symptoms of fever macker and Mandelbaum reported that local
and lumbar pain of the patient were relieved. A reexami- irrigation with a large amount of antibiotic solution
nation was performed, and the CT revealed that the lesion
to treat mediastinal infection could dilute and effec-
significantly shrunk (Fig. 3B). Peripheral white blood cells
tively clear the infectious substances in the medias-
7.55
109/L, C-reactive protein 28.19 mg/L, blood urea
nitrogen 7.00 mmol/L, creatinine 100.20 mmoI/L, systolic tinum.11 Mueller et al. also reported that puncture
pressure: 129e136 mm Hg, diastolic pressure: 69e81 mm drainage and systemic antiinflammatory therapy
Hg, blood cultures were negative. The patient continued could be used as a transitional treatment for high-
to orally receive Faropenem after discharge. One year risk patients before open surgery.12 Puncture and
has elapsed since the treatment, and the patient has drainage are simple to perform during operation
shown no evidence of a recurrence of the infection. He and can be repeatedly used, and these have been
is currently under outpatient monitoring, and long-term accepted by most patients. However, it is difficult
followup is necessary. to effectively control the infection, with systemic
antiinflammation alone.13 When the infection is un-
DISCUSSION controllable, artificial graft resection and revascular-
ization are necessary.14
All implanted aortic prostheses are at risk of infec- The present data reveal that the effect of surgical
tion either at implantation or later by hematogenous treatment for intra-aortic graft infection was supe-
seeding.4 The incidence of artificial graft infection rior to that of conservative treatment.2 Surgical
following EVAR and (OSR) open surgery repair for treatment is the best way to cure intra-aortic graft
an abdominal aortic aneurysm is similar.5 Factors infection, and conservative treatment without surgi-
for graft infection include an emergent indication cal intervention has a higher mortality rate.15 Mou-
for the initial surgery and the need for surgical revi- lakalis et al. reported that the mortality rate of
sion.6 Clinical practice guidelines of the American conservative treatment during hospitalization can
Society for Vascular Surgery in 2018 recommend: reach as high as 42.0e81.8%, which was signifi-
(1) In patients presenting with an infected graft in cantly higher than that of surgical treatment.16 The
the presence of extensive contamination with gross limitation of puncture drainage and systemic antiin-
purulence, extra-anatomic reconstruction followed flammation is that the infected graft cannot be
by excision of all graft material along with aortic completely removed, and the possibility of recur-
stump closure covered by an omental flap. (2) In pa- rence of infection is high. However, when the pa-
tients presenting with an infected graft with minimal tient has a poor health condition, has many
contamination, in situ reconstruction with cryopre- underlying diseases and old in age, puncture
served allograft. (3) In a stable patient presenting drainage and systemic antiinflammatory therapy
with an infected graft, in situ reconstruction with may be the options.17 Cernohorsky et al. reported
femoral vein after graft excision and d ebridement. that five patients underwent conservative treat-
(4) In unstable patients with infected graft, in situ ment, and good results were achieved. They recom-
reconstruction with a silver- or antibiotic- mended that when patients could not tolerate open
impregnated graft, cryopreserved allograft, or PTFE surgery, conservative treatment should be chosen.18
graft. (5) In patients unfit to undergo open repair, Setacci et al. also reported that 102 high-risk patients
percutaneous drainage, and antibiotic therapy.7 underwent puncture drainage and systemic antiin-
Although theoretically feasible, extra-anatomic flammatory therapy, and the survival rate was
reconstruction and situ reconstruction are not a acceptable. They advocated a flexible approach to
reasonable choice risk for every patient.8 aortic endograft infections, with conservative ther-
The patient underwent puncture and drainage, apy in high-risk patients.19 Indeed, these reports
local irrigation and systemic antiinflammation, and lack long-term follow-up results, and there is no
graft infection was controlled. Intermittent local irri- long-term evidence-based information about this.
gation can effectively remove pus tissue and fibrin
clots in order to prevent obstruction of the channel
between the lesion cavity and drainage tube.1 Simi- CONCLUSION
larly, infective material, destructive enzymes, path-
ogens, and large quantities of fibrin, clots, and Systemic antiinflammatory therapy and puncture
other debris are continuously washed out.1 Local drainage may be an option for high-risk patients
irrigation can maintain a high concentration of anti- with artificial graft infection after endovascular
biotics in the lesions to reduce the damage of aneurysm repair (EVAR). Although this cannot
289.e6 Case reports Annals of Vascular Surgery

eradicate the lesion, it can be effectively re- graft infection caused by methicillin-resistant Staphylo-
performed. Efforts should be performed to best con- coccus aureus. Eur J Vasc Endovasc Surg 2011;41:278e80.
9. Thurer RJ, Bognolo D, Vargas A, et al. The management of
trol the infection with close followup, in order to mediastinal infection following cardiac surgery. An experi-
prolong the survival of patients. However, as it ence utilizing continuous irrigation with povidone-iodine.
was only a single case, more evidence-based J Thorac Cardiovasc Surg 1974;68:962e8.
research is warranted. 10. Merrill WH, Akhter SA, Wolf RK, et al. Simplified treatment
of postoperative mediastinitis. Ann Thorac Surg 2004;78:
608e12.
11. Shumacker HB, Mandelbaum I. Continuous antibiotic irri-
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