Treatment Strategies and Outcomes of Infections After Carotid Interventions

Abstract

Infections after carotid endarterectomy are a devastating but rare complication, with paucity of literature providing guidelines for management of this complex issue. In this study, we report the experience of a single institution's management of carotid infections occurring after carotid interventions. A retrospective chart review was performed to document presentation, treatment, and outcomes of patients who underwent surgical intervention for carotid infections from 2002 to 2017. Primary end points were mortality and stroke. Secondary end points were cranial nerve injuries, reinfections, and reinterventions. Twenty-nine patients with mean age of 69 ± 2 years (76% male) were treated for carotid infections. Index operation was performed elsewhere in 27 (93%) patients, and 7 (24%) of these patients had prior secondary reinterventions (4 had carotid stenting and 3 had surgical revisions). The most common symptom on presentation was abscess or purulent drainage in 19 (66%) patients; 7 (24%) patients presented with active bleeding, and 10 (34%) patients had carotid pseudoaneurysms. Computed tomography was the diagnostic imaging of choice in 27 of 29 (93%) patients. Incision and drainage were performed in seven patients (five of these were done elsewhere before transfer). Wound and blood cultures were positive in 16 and 2 patients, respectively; the most common organisms identified were staphylococcus and streptococcus (83%). A combination of prosthetic (n = 15) and bovine (n = 5) patches was used at index operation. Median time to presentation was 7 months (range, 0.3-194 months). Femoral vein graft interposition was used for carotid replacement in 24 patients (83%), femoral vein patch angioplasty in 1 (3%), and saphenous vein patch angioplasty in 4 (14%). Early complications included stroke in one patient (3%) and death in one patient on postoperative day 11 from multiorgan system failure (3%). Three patients had tracheostomy (one for prolonged ventilator dependence, one had bilaterally paretic vocal cords, and one had a history of radiation therapy for laryngeal cancer). Cranial nerve injury occurred in eight patients (28%); all resolved at last follow-up. Mean length of hospital stay was 10 ± 1 days. Carotid occlusion occurred in one patient (3%) at 3 months with no clinical sequelae. Follow-up duplex ultrasound did not show any evidence of graft stenosis. At mean follow-up of 17 ± 4 months, there were no carotid reinfections or reinterventions. Treatment of carotid infections with replacement using femoral vein can be performed safely with a low risk of stroke and mortality. This repair is durable at midterm follow-up without clinical complications of reinfection or reintervention.