Septic complications after cardiac catheterization and percutaneous transluminal coronary angioplasty R o b e r t A. McCready, M D , H a r r y Siderys, M D , John N. Pittman, M D , Gilbert T. H e r o d , M D , H a r o l d G. H a l b r o o k , M D , J o h n W. Fehrenbacher, M D , Daniel J. Beckman, M D , and David A. H o r m u t h , M D , Indianapolis, Ind. Septic complications after cardiac catheterization and percutaneous transluminal coronary artery angioplasty are distinctly uncommon. However, we have recently treated nine patients with sepsis and life-threatening complications after cardiac catheterization alone or after catheterization and subsequent percutaneous transluminal coronary angioplasty. The common denominator in all patients was either repeat puncturing of the ipsilateral femoral artery or leaving the femoral artery sheath in for I to 5 days after the procedure. Two patients died as a direct result of their septic complications. One death occurred in a patient in whom bacterial endocarditis with congestive heart failure developed, and the other patient had a large retroperitoneal hematoma that became secondarily infected. Infected aneurysms that were successfully treated developed in three patients. Our study suggests that colonization of the needle tract by skin flora predisposes to septic complications if repeat arterial punctures are required or if a femoral artery sheath is left in place for more than 24 hours. Patients in whom sepsis develops after these procedures should be initially treated with antibiotics effective against gram-positive organisms. CT scanning or angiography should be considered for patients with persistent sepsis, septic emboli, and abdominal or flank pain. Infected aneurysms require resection or ligation because of the propensity of these aneurysms to rupture. (J Vase Svwa 1991;14:170-4.)
Vascular complications associated with cardiac catheterization and percutaneous transluminal coronary angioplasty (PTCA) include acute arterial occlusion, dissection, and hematoma or pseudoaneurysm formation. Septic complications are distinctly uncommon. However, we have recently treated nine patients with sepsis in w h o m life-threatening complications developed after cardiac catheterization alone or after catheterization and subsequent PTCA. The purpose of this report is to review the predisposing factors that led to these life-threatening complications, as well as to discuss the management of these problems. CLINICAL MATERIAL From October 1987 until October 1989 we identified nine patients in w h o m septic complications developed after either cardiac catheterization alone (one patient) or after cardiac catheterization and From the Divisionof Cardiovascular Surgery,Methodist Hospital of Indiana, Indianapolis. Reprint requests: Robert A. McCready, MD, 1801 North Senate Blvd., Suite 755, Indianapolis, IN 46202. 24/1/29134 170
PTCA (eight patients). Three of the latter eight patients underwent cardiac catheterization and PTCA as combined procedures, whereas in five patients the cardiac catheterization and PTCA were performed as staged procedures. In patients undergoing staged procedures, the subsequent PTCA was performed by repeat percutancous puncture of the ipsilateral femoral artery from 2 to 7 days after the diagnostic catheterization. The clinical characteristics, as well as the treatment and outcome of these patients, are listed in Table I. Signs of sepsis developed in patients from 1 to 5 days after the last invasive procedure. The signs of sepsis included fever, leukocytosis, bacteremia, and infected femoral artery puncture sites. Infectcd aneurysms requiring resection developed in three patients, and three patients had septic emboli. One patient had septic arthritis, with the same organism (Staphylococcus aureus) being cultured from the infected joint as was cultured from the blood. Two deaths were directly related to the septic complications (patients 5 and 6). The first death occurred in a patient who had aortic valve insufficiency with fulminate congestive heart failure as a
Volume 14 Number 2 August 1991
Septic complications after cardiac c~,rtheterization and PTCA
171
i
ry and Saphenous Vein)
/
Fern- Fern Graft
\
I I
Fig. 2. Artist's sketch illustrates the operative procedure performed on the patient with an infected right iliac artery anenrysm.
Fig. 1. Abdominal aortogram demonstrates a 4 cm irregular right common iliac artery aneurysm. result o f subacute bacterial endocarditis involving the aortic valve. She died o f disseminated intravascular coagulation and refractory heart failure 6 hours after urgent aortic valve replacement. T h e second death occurred in a patient with a retroperitoneal h e m a t o m a , which became secondarily infected resulting in an abscess along the psoas muscle. This patient also had thrombosis o f the inferior vena cava and ileofemoral veins. T h e following case s u m m a r y illustrates the salient clinical features observed in a patient in. w h o m an infected aneurysm developed. CASE REPORT
This 65-year-old woman was admitted to Methodist Hospital on Nov. 25, 1987, with an acute inferior myocardial infarction and congestive heart failure. In 1985 the patient had an anterior myocardial infarction caused by occlusion of the left anterior descending coronary artery. On the date of admission (Nov. 25, 1987) the patient underwent emergent cardiac catheterization by way of the right femoral artery. The catheterization demonstrated a high-grade stenosis of the right coronary artery with fresh thrombus. A large apical aneurysm was present, and there was hypokinesis on the inferior wall. The eiection fraction
was approximately 15%..~ffter thrombolytic therapy, a PTCA of the right coronary artery lesion was performed. The right femoral artery sheath was left in after the PTCA. On Nov. 27, 1987, recurrent chest pain developed in the patient. Repeat catheterization demonstrated residual stenosis of the right coronary artery, and repeat angioplasty was performed. The femoral artery sheath was removed on Nov. 28, 1987, (3 days after insertion). On Nov. 29, 1987, sepsis developed, and the patient had a fever (temperature, 102 ° F), leukocytosis (white blood cell count [WBC] of 23,500), and bacteremia (coagulase-positive S. aureus). The patient received 8 days of intravenous cefamanadole nafate (Mandol) and was subsequently discharged from the hospital with a normal WBC and a normal temperature. On Dec. 7, 1987, the patient Was admitted to her local hospital with recurrent fever (temperature, 39.4 ° C) and abdominal pain. Repeat blood cultures again grew coagulase-positive S. aureus, and she was given vancomycin and tobramycin. Results of an abdominal CT scan on Dec. 7, 1987, were negative. Abdominal ultrasonography on December 22 demonstrated right hydronephrosis. The serum creatinine level had also risen to 2.3 mg/dl. On December 23 the patient was transferred to Methodist Hospital. A cine CT scan of the abdomen performed on December 24 demonstrated the following: (1) thrombosis of the inferior vena cava and right common iliac vein caused by compression by a 4 cm right common iliac aneurysm and (2) obstruction of the right ureter. Aortography confirmed the presence of a right common iliac artery aneurysm (Fig. 1). Our plan was to do a left-to-right femorofemoral bypass followed by resection and ligation of the right iliac aneurysm. A left-to-right femorofemoral bypass with an 8 m m polytetrafluoroethylene graft was done as the first
5ournal of VASCULAR
172
SURGERY
McCready et al.
T a b l e I. Clinical characteristics and clinical o u t c o m e in nine patients Patient number
Age~Sex
Procedures
No. of days femoral sheath in
1
59 yr/male
Cath 4/6/89, PTCA 4/10/89
5
2
70 yr/female
3
65 yr/female
Cath 11/19/87, PTCA 11/23/87, Cath 11/24/87 Cath, PTCA 11/25/87, Cath, PTCA 11/27/87
0 2 3
4
71 yr/female
Cath 10/27/89, PTCA 10/31/89
2
5
56 yr/female
Cath 12/4/87, PTCA 12/11/87
2
6
74 yr/female
Cath 5/18/89
2
7
57 yr/male
Cath 10/24/89, PTCA 10/24/89
2
8
51 yr/male
Cath, PTCA, 7/26/90, Cath, PTCA 7/27/90
3
9
46 yr/male
Cath, PTCA, 8/]/90
Unknown
Clinical presentation
Temperature 39.4 ° C, WBC (24,000), groin bematoma, septic emboli, femoral pseudoaneurysm Temperature 37,9 ° C, WBC (13,000), groin hematoma, septic emboli, Osler's nodes Temperature (38.8 ° C), WBC (23,500), (R) iliac artery aneurysm, IVC thrombosis, hydronephrosis Temperature (38.6 ° C), WBC (25,000), septic athritis, infected groin bematoma Temperature (40 ° C), CHF, AI Temperature (40.4 ° C), WBC (22,000), psoas abscess Temperature (40 ° C), WBC (13,000), infected groin hematoma Temperature (39.3 ° C), WBC (14,700), groin hematoma, septic emboli, AAA and iliac aneurysms Temperature (40 ° C), WBC (12,000)
Cath, Catheterization; PTCA, percutaneous transluminal coronary angioptasty; WBC, white blood count; IVC, inferior vena cava; CHF, congestive heart failure; AI, aortic insufficiency; AAA, abdominal aortic aneurysm; SFA, superficial femoral artery. portion of the procedure. At abdominal exploration, however, severe inflammatory changes surrounded the aneurysm, which also involved the distal abdominal aorta and the proximal left common lilac artery. In addition, several large venous collateral vessels formed as a result of thrombosis of the inferior vena cava. Because of these inflammatory changes, we elected to resect the distal abdominal aorta and both common iliac arteries. To maintain flow to the pelvis and lower extremities, a composite graft consisting of saphenous vein and endarterectomized right external-right iliac artery was anastomosed to the proximal aorta and distally to the left common lilac artery (Fig. 2). A composite graft was necessary because only the proximal portion of the saphenous vein was large enough to provide flow to both lower extremities. Because of the extensive venous thrombosis, a Greenfield filter was inserted by way of the right internal jugular vein. After operation transient renal failure developed in the patient, but no dialysis was required. The consulting nephrologist attributed the renal dysfunction to the multiple antibiotics the patient received. She received a total of 6 weeks of intravenous vancomycin as well as 2 weeks of cefazolin sodium (Kefzol). Renal function slowly returned to normal after the antibiotics were discontinued. An abdominal ultrasound scan showed resolution of the hydronephrosis. At 36-month follow-up the patient remains free of infection. The resulting anlde/brachial indexes are 0.84 on the right and 0.81 on the left. The patient does not have symptoms of claudication, although her exercise capacity is limited by her underlying cardiac disease:.
DISCUSSION Vascular complications after diagnostic cardiac catheterization or P T C A include h e m a t o m a or pseud o a n e u r y s m formation, subintimal dissection resulting in acute arterial occlusion, thrombosis, and distal embolization. Septic complications, either local or systemic, are distinctly u n c o m m o n . F e m o r a l artery aneurysms or pseudoaneurysms have been reported as complications after P T C A , arteriography, and insertion o f intraaortic balloon pumps.l-4 S o d e r s t r o m et al.1 described six patients in w h o m infected femoral artery pseudoaneurysms developed as a result o f indwelling femoral artery catheters, all o f which had been inserted for h e m o dynamic m o n i t o r i n g purposes. 1 S. aureus was cultured in five patients and S. epidermidis in one patient. F e m o r a l artery aneurysms are n o w the m o s t c o m m o n type o f infected aneurysm, accounting for 38% o f the infected aneurysms in the literature review by B r o w n et al. 5 T r a u m a was the cause o f the aneurysms in m o s t patients. Iliac endarteritis after percutaneous angioplasty o f an lilac stenosis has been reported. 6 This patient had septic arthritis and septic emboli f r o m which S. aureus organisms were cultured. T h e patient r e s p o n d e d to intensive antibiotic therapy, and no surgical intervention was needed. There have been several isolated reports o f infected aneurysms or aortic infections after either
Volume 14 Number 2 August 1991
Septic complications after cardiac ca,theterization and P T C A
Aneurysm cultures
Blood cultures
Antibiotic treatment
S. aureus (coag-pos)
Proteus, Escherichia c o l i , enterococcus bacteroides fragilis
Vancomycin, nafcillin
S. aureus (coag-pos)
None
Vancomycin, nafcillin
S. aureus (coag-pos)
Negative
S. aureus (coag-pos)
None
Mandol, ceftriaxone sodium (Rocephin), nafcillin, vancomycin Vancomycin, nafcillin
S. aureus (coag-pos)
Aortic valve-negative
S. aureus (coag-pos)
~urgical treatment
Right external iliac to SFA bypass, excision, pseudoaneurysm None
173
Outcome
Recovered Recovered
Resection right iliac artery aneurysm
Recovered
None
Recovered
Aortic valve replacement
Died
None
Erythomyin, clindamycin, gentamycin, Kefzol Vancomycin, Rocephin
None
Died
Group A B-hemolytic strep S. aureus (coag-pos)
None
Kefzol
None
Recovered
s. aureus (coag-pos)
Kefzol, vancomycin, gentamycin
Resection of AAA with aortofemoral bypass
Recovered
S. aureus (coag-pos)
None
Vancomycin, Kefzol
None
Recovered
arteriographic or cardiac catheterization s t u d i e s . 7"11 Although the term "mycotic aneurysm" has been used extensively in the past, Jarrett et al. 11 suggested that the term "infected aneurysm" is more accurate because fungi are rarely involved. They listed three potential causes of infected aneurysms: (1) septic arterial emboli from bacterial endocarditis, (2) direct extension of an adjacent infectious process or from the lymphatics surrounding an infectious process or from the lymphatics surrounding an infectious process, and (3) the hematogenous seeding of an arterial wall during bacteremia from a distant focus other than the heart. Baker et al.7 have suggested that inoculation of an atheromatous aorta with bacteria from percutaneous femoral artery catheterization should be added to the list of causes of infected aneurysms. Pathologically, the infection involves portions of the aorta and iliac arteries that are weakened by congenital or acquired disease? ~ An acute inflammatory response then develops that can lead to erosion and rupture that can occur with or without aneurysmal dilation? ~ Infected femoral artery aneurysms or pscudoaneurysms are prone to rupture or thrombosis with an attendant risk of limb loss. 13-14 We believe the key factor that resulted in the septic complications seen in our patients was either repeat percutaneous puncture of the same femoral artery or that the femoral artery sheath was left in for 1 to 5 days after the initial invasive procedure. In most of our patients both risk factors were present. 9
In addition, several patients had oozing around the femoral artery sheath leading to development of a hematoma further increasing the risk of infection. In a series of three patients with septic complications (bacteremia in two and an infected pseudoaneurysm in one) after a repeat PTCA, Evans and Goldstein 2 noted that the repeat PTCA had been performed by percutaneous puncture of the same femoral artery. S. aureus organisms were cultured from all three patients. The inguinal region seems especially susceptible to infectious complications after invasive diagnostic or therapeutic procedures. Most series of prosthetic graft infections after operations on the abdominal aorta have documented a twofold increase in the infection rate when the distal anastomoses involve the femoral artery or when multiple operations in the same groin are required.lslr Among the explanations for the increased risk of inguinal incisions to wound complications and sepsis is chronic colonization of the skin in the groin by S. aureus and other pathogens, especially in patients who are obese? 8 Inoculation of the needle tract with skin flora undoubtedly increases the risk of septic complications if repeat arterial punctures are required. If repeat arterial punctures are required for either diagnostic or therapeutic purposes, we recommend choosing an alternative access site. In addition, the femoral artery sheath should be removed as soon as possible after the procedure. Patients with signs of sepsis after these procedures should be given intra-
174
Journal of VASCULAR SURGERY
McCready et al.
venous antibiotics that are effective against grampositive organisms (S. aureus) pending the results of cultures. CT scanning or arteriography should be considered for patients with persistent fever, septic emboli, and flank, abdominal, or groin pain. Infected aneurysms require resection or ligation of the aneurysm because of the propensity of the infectious process to lead to arterial wall disruption with its attendant high morbidity and mortality rates.
9.
10.
11.
12. REFERENCES
1. Soderstrom CA, Wasserman DH, Ransom KJ, Caplan ES, Cowley RA. Infected false femoral artery, aneurysms secondary to monitoring catheters. J Cardiovasc Surg 1983;24: 63-8. 2. Evans BH, Goldstein EJC. Increased risk of infection after repeat percutaneous transluminal coronary angioplasty. Am l Infect Control 1987;15:125-6. 3. Patel S, lohnston KW. Classification and management of mycotic ancurysms. Surg Gynecol Obstet 1977;144:691-4. 4. Grantham RN, Munell ER, Kanaly PJ. Femoral artery infection complicating intraaortic balloon pumping. Am J Surg 1983;146:811-4. 5. Brown SL, Busuttil RW, Baker JD, Machleder HI, Moore WS, Barker WF. Bacteriologic and surgical determinants of survival in patients with mycotic ancurysms. J VASC SUV,G 1984;1:541-7. 6. Krupski WC, Pogany A, Effeney DJ. Septic endarteritis after percutaneous transluminal angioplasty. Surgery 1985;98: 359-61. 7. Baker Wt-I, Moran JM, Dormer DB. Infected aortic aneurysms following arteriography. J Cardiovasc Surg 1979;20: 373-7. 8. McCready RA, Hyde GL, Mattingly SS. Infected abdominal
13.
14.
15.
16.
I7.
18.
aortic aneurysm following transfemoral arteriography: case report. Contemp Surg 1988;32:37-44. Munduth ED, Darling RC, Alvarado R_H, Buckley MJ, Linton RR, Austen WG. Surgical management of mycotic aneurysms and the complications of infection in vascular reconstructive surgery. Am J Surg 1969;117:460-70. Cullen PJ, Leahy AL, McBride KD, Moore KD, Moore DJ, Shanik GD. Angiographically-inducedinfection of the aorta. Ann Vasc Surg 1986;1:386-8. Jarrett F, Darling RC, Munduth ED, Austen WG. Experience with infected aneurysms of the abdominal aorta. Arch Surg 1975;110:1281-6. Bennett DE. Primary mycotic aneurysms of the aorta. Arch Surg 1967;94:758-65. Reddy DJ, Smith RF, Elliott IP, Haddad GK, Wanek EA. Infected femoral artery false aneurysms in drug addicts; evolution of selective vascular reconstruction. J VASe SURG 1986;3:718-24. Feldman AI, Berquer R. Management of infected aneurysm of the groin secondary to drug abuse. Surg Gynecol Obstet 1983;157:519-22. Leib,veg WG, Greenfield LJ. Vascular prosthetic infections: collected experience/and results of treatment. Surgery 1977; 81:335-42. Lorentzen JE, Neilsen OM, Arendrup H, et al. Vasculargraft infection: an analysis of sixty-two graft infections in 2411 consecutively implanted synthetic vascular grafts. Surgery 1985;98:81-6. Landreneau MD, Raju S. Infections after elective bypass surgery for lower limb ischemia:the influenceof preoperative transcutaneous arteriography. Surgery 1981;90:956-61. SzilagyiDE, Smith RF, Elliot JP, VrandecicMP. Infection in arterial reconstruction with synthetic grafts. Ann Surg 1972; 176:321-33.
Submitted Oct. 9, 1990; accepted Feb. 26, 1991.
Vascular complications associated with cardiac catheterization and percutaneous transluminal coronary angioplasty (PTCA) include acute arterial occlusion, dissection, and hematoma or pseudoaneurysm formation. Septic complications are distinctly uncommon. However, we have recently treated nine patients with sepsis in w h o m life-threatening complications developed after cardiac catheterization alone or after catheterization and subsequent PTCA. The purpose of this report is to review the predisposing factors that led to these life-threatening complications, as well as to discuss the management of these problems. CLINICAL MATERIAL From October 1987 until October 1989 we identified nine patients in w h o m septic complications developed after either cardiac catheterization alone (one patient) or after cardiac catheterization and From the Divisionof Cardiovascular Surgery,Methodist Hospital of Indiana, Indianapolis. Reprint requests: Robert A. McCready, MD, 1801 North Senate Blvd., Suite 755, Indianapolis, IN 46202. 24/1/29134 170
PTCA (eight patients). Three of the latter eight patients underwent cardiac catheterization and PTCA as combined procedures, whereas in five patients the cardiac catheterization and PTCA were performed as staged procedures. In patients undergoing staged procedures, the subsequent PTCA was performed by repeat percutancous puncture of the ipsilateral femoral artery from 2 to 7 days after the diagnostic catheterization. The clinical characteristics, as well as the treatment and outcome of these patients, are listed in Table I. Signs of sepsis developed in patients from 1 to 5 days after the last invasive procedure. The signs of sepsis included fever, leukocytosis, bacteremia, and infected femoral artery puncture sites. Infectcd aneurysms requiring resection developed in three patients, and three patients had septic emboli. One patient had septic arthritis, with the same organism (Staphylococcus aureus) being cultured from the infected joint as was cultured from the blood. Two deaths were directly related to the septic complications (patients 5 and 6). The first death occurred in a patient who had aortic valve insufficiency with fulminate congestive heart failure as a
Volume 14 Number 2 August 1991
Septic complications after cardiac c~,rtheterization and PTCA
171
i
ry and Saphenous Vein)
/
Fern- Fern Graft
\
I I
Fig. 2. Artist's sketch illustrates the operative procedure performed on the patient with an infected right iliac artery anenrysm.
Fig. 1. Abdominal aortogram demonstrates a 4 cm irregular right common iliac artery aneurysm. result o f subacute bacterial endocarditis involving the aortic valve. She died o f disseminated intravascular coagulation and refractory heart failure 6 hours after urgent aortic valve replacement. T h e second death occurred in a patient with a retroperitoneal h e m a t o m a , which became secondarily infected resulting in an abscess along the psoas muscle. This patient also had thrombosis o f the inferior vena cava and ileofemoral veins. T h e following case s u m m a r y illustrates the salient clinical features observed in a patient in. w h o m an infected aneurysm developed. CASE REPORT
This 65-year-old woman was admitted to Methodist Hospital on Nov. 25, 1987, with an acute inferior myocardial infarction and congestive heart failure. In 1985 the patient had an anterior myocardial infarction caused by occlusion of the left anterior descending coronary artery. On the date of admission (Nov. 25, 1987) the patient underwent emergent cardiac catheterization by way of the right femoral artery. The catheterization demonstrated a high-grade stenosis of the right coronary artery with fresh thrombus. A large apical aneurysm was present, and there was hypokinesis on the inferior wall. The eiection fraction
was approximately 15%..~ffter thrombolytic therapy, a PTCA of the right coronary artery lesion was performed. The right femoral artery sheath was left in after the PTCA. On Nov. 27, 1987, recurrent chest pain developed in the patient. Repeat catheterization demonstrated residual stenosis of the right coronary artery, and repeat angioplasty was performed. The femoral artery sheath was removed on Nov. 28, 1987, (3 days after insertion). On Nov. 29, 1987, sepsis developed, and the patient had a fever (temperature, 102 ° F), leukocytosis (white blood cell count [WBC] of 23,500), and bacteremia (coagulase-positive S. aureus). The patient received 8 days of intravenous cefamanadole nafate (Mandol) and was subsequently discharged from the hospital with a normal WBC and a normal temperature. On Dec. 7, 1987, the patient Was admitted to her local hospital with recurrent fever (temperature, 39.4 ° C) and abdominal pain. Repeat blood cultures again grew coagulase-positive S. aureus, and she was given vancomycin and tobramycin. Results of an abdominal CT scan on Dec. 7, 1987, were negative. Abdominal ultrasonography on December 22 demonstrated right hydronephrosis. The serum creatinine level had also risen to 2.3 mg/dl. On December 23 the patient was transferred to Methodist Hospital. A cine CT scan of the abdomen performed on December 24 demonstrated the following: (1) thrombosis of the inferior vena cava and right common iliac vein caused by compression by a 4 cm right common iliac aneurysm and (2) obstruction of the right ureter. Aortography confirmed the presence of a right common iliac artery aneurysm (Fig. 1). Our plan was to do a left-to-right femorofemoral bypass followed by resection and ligation of the right iliac aneurysm. A left-to-right femorofemoral bypass with an 8 m m polytetrafluoroethylene graft was done as the first
5ournal of VASCULAR
172
SURGERY
McCready et al.
T a b l e I. Clinical characteristics and clinical o u t c o m e in nine patients Patient number
Age~Sex
Procedures
No. of days femoral sheath in
1
59 yr/male
Cath 4/6/89, PTCA 4/10/89
5
2
70 yr/female
3
65 yr/female
Cath 11/19/87, PTCA 11/23/87, Cath 11/24/87 Cath, PTCA 11/25/87, Cath, PTCA 11/27/87
0 2 3
4
71 yr/female
Cath 10/27/89, PTCA 10/31/89
2
5
56 yr/female
Cath 12/4/87, PTCA 12/11/87
2
6
74 yr/female
Cath 5/18/89
2
7
57 yr/male
Cath 10/24/89, PTCA 10/24/89
2
8
51 yr/male
Cath, PTCA, 7/26/90, Cath, PTCA 7/27/90
3
9
46 yr/male
Cath, PTCA, 8/]/90
Unknown
Clinical presentation
Temperature 39.4 ° C, WBC (24,000), groin bematoma, septic emboli, femoral pseudoaneurysm Temperature 37,9 ° C, WBC (13,000), groin hematoma, septic emboli, Osler's nodes Temperature (38.8 ° C), WBC (23,500), (R) iliac artery aneurysm, IVC thrombosis, hydronephrosis Temperature (38.6 ° C), WBC (25,000), septic athritis, infected groin bematoma Temperature (40 ° C), CHF, AI Temperature (40.4 ° C), WBC (22,000), psoas abscess Temperature (40 ° C), WBC (13,000), infected groin hematoma Temperature (39.3 ° C), WBC (14,700), groin hematoma, septic emboli, AAA and iliac aneurysms Temperature (40 ° C), WBC (12,000)
Cath, Catheterization; PTCA, percutaneous transluminal coronary angioptasty; WBC, white blood count; IVC, inferior vena cava; CHF, congestive heart failure; AI, aortic insufficiency; AAA, abdominal aortic aneurysm; SFA, superficial femoral artery. portion of the procedure. At abdominal exploration, however, severe inflammatory changes surrounded the aneurysm, which also involved the distal abdominal aorta and the proximal left common lilac artery. In addition, several large venous collateral vessels formed as a result of thrombosis of the inferior vena cava. Because of these inflammatory changes, we elected to resect the distal abdominal aorta and both common iliac arteries. To maintain flow to the pelvis and lower extremities, a composite graft consisting of saphenous vein and endarterectomized right external-right iliac artery was anastomosed to the proximal aorta and distally to the left common lilac artery (Fig. 2). A composite graft was necessary because only the proximal portion of the saphenous vein was large enough to provide flow to both lower extremities. Because of the extensive venous thrombosis, a Greenfield filter was inserted by way of the right internal jugular vein. After operation transient renal failure developed in the patient, but no dialysis was required. The consulting nephrologist attributed the renal dysfunction to the multiple antibiotics the patient received. She received a total of 6 weeks of intravenous vancomycin as well as 2 weeks of cefazolin sodium (Kefzol). Renal function slowly returned to normal after the antibiotics were discontinued. An abdominal ultrasound scan showed resolution of the hydronephrosis. At 36-month follow-up the patient remains free of infection. The resulting anlde/brachial indexes are 0.84 on the right and 0.81 on the left. The patient does not have symptoms of claudication, although her exercise capacity is limited by her underlying cardiac disease:.
DISCUSSION Vascular complications after diagnostic cardiac catheterization or P T C A include h e m a t o m a or pseud o a n e u r y s m formation, subintimal dissection resulting in acute arterial occlusion, thrombosis, and distal embolization. Septic complications, either local or systemic, are distinctly u n c o m m o n . F e m o r a l artery aneurysms or pseudoaneurysms have been reported as complications after P T C A , arteriography, and insertion o f intraaortic balloon pumps.l-4 S o d e r s t r o m et al.1 described six patients in w h o m infected femoral artery pseudoaneurysms developed as a result o f indwelling femoral artery catheters, all o f which had been inserted for h e m o dynamic m o n i t o r i n g purposes. 1 S. aureus was cultured in five patients and S. epidermidis in one patient. F e m o r a l artery aneurysms are n o w the m o s t c o m m o n type o f infected aneurysm, accounting for 38% o f the infected aneurysms in the literature review by B r o w n et al. 5 T r a u m a was the cause o f the aneurysms in m o s t patients. Iliac endarteritis after percutaneous angioplasty o f an lilac stenosis has been reported. 6 This patient had septic arthritis and septic emboli f r o m which S. aureus organisms were cultured. T h e patient r e s p o n d e d to intensive antibiotic therapy, and no surgical intervention was needed. There have been several isolated reports o f infected aneurysms or aortic infections after either
Volume 14 Number 2 August 1991
Septic complications after cardiac ca,theterization and P T C A
Aneurysm cultures
Blood cultures
Antibiotic treatment
S. aureus (coag-pos)
Proteus, Escherichia c o l i , enterococcus bacteroides fragilis
Vancomycin, nafcillin
S. aureus (coag-pos)
None
Vancomycin, nafcillin
S. aureus (coag-pos)
Negative
S. aureus (coag-pos)
None
Mandol, ceftriaxone sodium (Rocephin), nafcillin, vancomycin Vancomycin, nafcillin
S. aureus (coag-pos)
Aortic valve-negative
S. aureus (coag-pos)
~urgical treatment
Right external iliac to SFA bypass, excision, pseudoaneurysm None
173
Outcome
Recovered Recovered
Resection right iliac artery aneurysm
Recovered
None
Recovered
Aortic valve replacement
Died
None
Erythomyin, clindamycin, gentamycin, Kefzol Vancomycin, Rocephin
None
Died
Group A B-hemolytic strep S. aureus (coag-pos)
None
Kefzol
None
Recovered
s. aureus (coag-pos)
Kefzol, vancomycin, gentamycin
Resection of AAA with aortofemoral bypass
Recovered
S. aureus (coag-pos)
None
Vancomycin, Kefzol
None
Recovered
arteriographic or cardiac catheterization s t u d i e s . 7"11 Although the term "mycotic aneurysm" has been used extensively in the past, Jarrett et al. 11 suggested that the term "infected aneurysm" is more accurate because fungi are rarely involved. They listed three potential causes of infected aneurysms: (1) septic arterial emboli from bacterial endocarditis, (2) direct extension of an adjacent infectious process or from the lymphatics surrounding an infectious process or from the lymphatics surrounding an infectious process, and (3) the hematogenous seeding of an arterial wall during bacteremia from a distant focus other than the heart. Baker et al.7 have suggested that inoculation of an atheromatous aorta with bacteria from percutaneous femoral artery catheterization should be added to the list of causes of infected aneurysms. Pathologically, the infection involves portions of the aorta and iliac arteries that are weakened by congenital or acquired disease? ~ An acute inflammatory response then develops that can lead to erosion and rupture that can occur with or without aneurysmal dilation? ~ Infected femoral artery aneurysms or pscudoaneurysms are prone to rupture or thrombosis with an attendant risk of limb loss. 13-14 We believe the key factor that resulted in the septic complications seen in our patients was either repeat percutaneous puncture of the same femoral artery or that the femoral artery sheath was left in for 1 to 5 days after the initial invasive procedure. In most of our patients both risk factors were present. 9
In addition, several patients had oozing around the femoral artery sheath leading to development of a hematoma further increasing the risk of infection. In a series of three patients with septic complications (bacteremia in two and an infected pseudoaneurysm in one) after a repeat PTCA, Evans and Goldstein 2 noted that the repeat PTCA had been performed by percutaneous puncture of the same femoral artery. S. aureus organisms were cultured from all three patients. The inguinal region seems especially susceptible to infectious complications after invasive diagnostic or therapeutic procedures. Most series of prosthetic graft infections after operations on the abdominal aorta have documented a twofold increase in the infection rate when the distal anastomoses involve the femoral artery or when multiple operations in the same groin are required.lslr Among the explanations for the increased risk of inguinal incisions to wound complications and sepsis is chronic colonization of the skin in the groin by S. aureus and other pathogens, especially in patients who are obese? 8 Inoculation of the needle tract with skin flora undoubtedly increases the risk of septic complications if repeat arterial punctures are required. If repeat arterial punctures are required for either diagnostic or therapeutic purposes, we recommend choosing an alternative access site. In addition, the femoral artery sheath should be removed as soon as possible after the procedure. Patients with signs of sepsis after these procedures should be given intra-
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venous antibiotics that are effective against grampositive organisms (S. aureus) pending the results of cultures. CT scanning or arteriography should be considered for patients with persistent fever, septic emboli, and flank, abdominal, or groin pain. Infected aneurysms require resection or ligation of the aneurysm because of the propensity of the infectious process to lead to arterial wall disruption with its attendant high morbidity and mortality rates.
9.
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1. Soderstrom CA, Wasserman DH, Ransom KJ, Caplan ES, Cowley RA. Infected false femoral artery, aneurysms secondary to monitoring catheters. J Cardiovasc Surg 1983;24: 63-8. 2. Evans BH, Goldstein EJC. Increased risk of infection after repeat percutaneous transluminal coronary angioplasty. Am l Infect Control 1987;15:125-6. 3. Patel S, lohnston KW. Classification and management of mycotic ancurysms. Surg Gynecol Obstet 1977;144:691-4. 4. Grantham RN, Munell ER, Kanaly PJ. Femoral artery infection complicating intraaortic balloon pumping. Am J Surg 1983;146:811-4. 5. Brown SL, Busuttil RW, Baker JD, Machleder HI, Moore WS, Barker WF. Bacteriologic and surgical determinants of survival in patients with mycotic ancurysms. J VASC SUV,G 1984;1:541-7. 6. Krupski WC, Pogany A, Effeney DJ. Septic endarteritis after percutaneous transluminal angioplasty. Surgery 1985;98: 359-61. 7. Baker Wt-I, Moran JM, Dormer DB. Infected aortic aneurysms following arteriography. J Cardiovasc Surg 1979;20: 373-7. 8. McCready RA, Hyde GL, Mattingly SS. Infected abdominal
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Submitted Oct. 9, 1990; accepted Feb. 26, 1991.
