Infection of Aortic Endoluminal Graft Following Internal Iliac Embolisation

Abstract

A 74-year-old gentleman presented for elective endoluminal repair of a 7 cm infrarenal aortic aneurysm and right common iliac aneurysm. Preoperative comorbidity included bilateral claudication, ischaemic heart disease, chronic obstructive airways disease and recent pulmonary embolism for which he was warfarinised. Pre-operatively he had the right internal iliac artery embolised with 14 Cook coils to prevent an endoleak as the right graft limb was to be to the external iliac. He had right hip and thigh claudication following this. A week later he had an EVAR using a Trifab Zenith graft (Cook). Both procedures were performed in a new angiology suite with sterile fields but prophylactic Cephazolin was used only for the EVAR. During the post-operative period after the EVAR he developed bilateral groin pain, a mildly increased temperature and rapid AF with reversion to sinus rhythm within 24 h on amiodarone. At 48 h his temperature remained elevated, and an abdominal CT scan showed some perigraft air which is often seen post EVAR. Antibiotics (IV metronidazole, amoxycilin and gentamicin) were commenced and continued until blood cultures were shown to be negative. Five days post-operatively he was afebrile. He was assumed to have had a graft related fever, and went home without antibiotics. Ten weeks after EVAR he presented for the third time with back, bilateral buttock and groin pain for which previous CT scans and blood cultures had been normal. On admission he had elevated platelets (631 £ 10/L ðN 1⁄4 150– 400Þ) and CRP (261 mg/L ðN 1⁄4 0– 8Þ) but a normal white cell count and a normal abdominal CT. Over the next 4 days he continued to have pain and spiking pyrexia. Clinically he was thought to have a graft infection and a Tc99 labeled white cell scan showed increased uptake in the abdominal aortic area (Fig. 1). A CT guided fine needle aspiration of the thrombus surrounding the endograft yielded Staphyloccus sp. He was started on vancomycin and prepared for surgical removal of the infected endoluminal graft. On opening the aneurysm pus was found coming mainly from the right common iliac artery in the area of the embolisation. The infected aneurysm sac and graft were excised and an aorto-biiliac silver-coated polyester graft soaked in rifampicin and wrapped in omentum was placed. The pus grew Staphyloccus aureus. He made a good recovery and was discharged home 10 days later. He was continued on oral rifampicin and oral cefuroxime for a further 6 months. At follow-up over the next 2 years he had no evidence of further graft infection. EJVES Extra 6, 122–123 (2003) doi: 10.1016/S1533-3167(03)00105-5, available online at http://www.sciencedirect.com on