
==== Front
Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00921-0
10.1016/j.ijscr.2024.110140
110140
Case Report
Early and severe aortic endograft infection after percutaneous coil embolization of type 2 endoleak: A case report
Balézeaux Quentin quentinbalezeaux@gmail.com
a⁎
Leroux Aurélie a
Krug Bruno b
Rondelet Benoit a
Belhaj Asmae a
a Department of Cardio-Vascular, Thoracic Surgery and Lung Transplantation, CHU UcL Namur, UcLouvain, Yvoir, Belgium
b Department of Nuclear Medicine, CHU UCL Namur, Godinne Site, Université Catholique de Louvain, Belgium
⁎ Corresponding author at: Department of Cardio-Vascular and Thoracic Surgery and Transplantation, CHU UcL Namur, Godinne, Avenue G. Therasse, 1, 5530 Yvoir, Belgium. quentinbalezeaux@gmail.com
10 8 2024
9 2024
10 8 2024
122 11014011 7 2024
31 7 2024
7 8 2024
© 2024 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Limited.
2024

https://creativecommons.org/licenses/by/4.0/ This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Introduction

Endovascular aneurysm repair for abdominal aortic aneurysm is superior to open surgery regarding perioperative morbidity and mortality. Complications such as endoleaks represent a significant source of secondary intervention. Vascular graft infection is another serious complication found in 0.2 to 1 % of series. We hereby describe a case of a rapidly progressive aortic infection by Cutibacterium acnes following a percutaneous embolization procedure for a type II endoleak.

Case presentation

A 75-year-old man presented with a fever along with lower back and buttock pain five days after embolization via direct percutaneous puncture for a type II endoleak. White blood cell scintigraphy and blood culture suggested the presence of aortitis, but the patient experienced notable spontaneous improvement in both clinical symptoms and biological markers. The patient underwent CT-angiography which revealed aneurysm rupture requiring urgent open surgery and initiation of antimicrobial therapy. Similarly to blood cultures, per-operative aortic wall tissue samples also revealed presence of Cutibacterium acnes.

Discussion

Aortic endograft infection after embolization is an uncommon complication. The diagnosis is based on a combination of imaging, blood, and nuclear tests. Repeated CT-angiography may be helpful when infection occurs quickly after embolization. Staphylococcus and Streptococci are common pathogens implicated in these infections.

Conclusions

This is a case of an early and severe aortic endograft infection after percutaneous coil embolization of type 2 endoleak. Rupture occurred in less two weeks despite a slow-growing organism infection. The treatment includes endograft removal and antibacterial therapy. Caution is warranted when suspecting aortic endoprosthesis infection, necessitating close follow-up.

Highlights

• This is a rare case of EVAR infection by Cutibacterium acnes after percutaneous coil embolization.

• EL2 should be managed when the aneurysm has increased by more than 10 mm in diameter.

• VGI often presents with atypical symptoms but patients usually have high white blood cell count, fever, and abdominal pain.

• Repeated CT-angiography and and nuclear imaging may be helpful when infection occurs quickly after embolization.

Keywords

Abdominal aortic aneurysm
Coil embolization
Endovascular aneurysm repair
Infection
Homograft
Case report
==== Body
pmc1 Introduction

Endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm is superior to open surgery (OS) regarding perioperative morbidity and mortality [1,2], but long-term survival remains comparable between the two techniques. Endoleaks (EL) represent a significant source of secondary intervention, sometimes occurring several years after the initial procedure [3] and requiring close follow-up when the aneurysm enlarges [4]. Vascular graft infection (VGI) is another serious complication found in 0.2 to 1 % of series [[2], [3], [4], [5]]. We hereby describe a case of an aortitis and rapid EVAR infection following a percutaneous embolization procedure for in our university hospital. This work was reported in line with the SCARE criteria [6] and informed consent was obtained from the patient and his family.

2 Case report

A 75-year-old patient underwent an EVAR procedure in 2022. In his medical history, he reports a hemorrhagic stroke, prostatic neoplasia treated with radiotherapy in complete remission, and a partial gastrectomy with vagotomy for gastro-duodenal ulcers. The EVAR procedure and postoperative course were uneventful. A one-year CT-scan follow-up revealed a type 2 endoleak (Fig. 1). The aneurysm size measured 56 mm (2 mm larger than preoperatively). Embolization via direct percutaneous puncture from the left posterolateral approach of the aneurysmal sac was performed (Fig. 2). This procedure involved embolization of a lumbar artery using diluted glue (two vials of Glubran®) with Lipiodol® at a 1:4 ratio. Five months after this procedure, a new CT-scan shows the persistence of the type II EL. A second lumbar artery embolization procedure is performed 17 months after the initial placement of the endograft. The patient was discharged the day after despite one episode of fever attributed to side effect of aneurysmal embolization. Due to the persistence of this fever and lower back and buttock pain, a CT-angiography was performed at day 3, revealing iodinated contrast used for embolization in the aneurysm with some air related to the recent procedure. There was no leakage or morphological changes of the aneurysm. The patient went on to experience daily fever spikes requiring readmission. A white blood cell scintigraphy was undergone and reported high suspicion of early VGI (Fig. 3). Surgical removal of the endograft was recommended. Meanwhile, the patient displayed spontaneous clinical and biological improvement. Surgical intervention was reconsidered, and a new CT-angiography was performed and revealed a modified aspect of the aneurysmal sac, with leakage of embolization material (Fig. 4). Urgent surgical management was decided. Concurrently, a blood culture came back positive for Cutibacterium acnes. The surgical approach was a midline laparotomy. Retroperitoneal exploration revealed no blood extravasation. After removal of the endograft, a localized rupture with purulent infiltration was found in the posterior wall of the aorta (Fig. 5). The subsequent procedure involved excising these infected tissues and performing an aorto-bi-iliac bypass (Intergard Synergy 20/10 prosthesis). Bacteriological tests of the tissues reveal the same Cutibacterium acnes as identified in the blood cultures. The patient received appropriate penicillin-based antibiotic therapy. Ten days after the operation, the postoperative course was satisfactory, including a decrease in white blood cell count and cessation of fever spikes. Unfortunately, the patient developed a spontaneous subdural hematoma with cerebellar compression. Despite prompt decompression by the neurosurgery team, the patient died 22 days after the vascular intervention.Fig. 1 CT scan with contrast, axial view: aneurysmal sac opacification in the right side of the aortic graft.

Fig. 1

Fig. 2 (a) Arteriography and (b) cone bean CT showing embolization of an lombar artery by aneurysmal sac direct puncture.

Fig. 2

Fig. 3 Planar images were taken at 60 min, 4 to 6 h and 24 h post-injection of 285 MBq of 99mTc-HMPAO-labelled white blood cells respectively. The accumulation of white blood cells in two foci was consistent with two septic foci. The SPECT/CT images at 4 to 6 h post-injection confirmed the presence of two foci of white blood cell accumulation in the distal part of the prosthesis.

Fig. 3

Fig. 4 CT scan of the rupture with the modification of the aneurysmal sac on the left side.

Fig. 4

Fig. 5 Per-operative photograph of the aorta posterior wall. Arrow showing the rupture site.

Fig. 5

3 Discussion

In our knowledge, this is the fourth case of early aortic endograft infection after percutaneous embolization for type 2 endoleak.

VGI is a concerning complication with poor prognosis. Vascular graft infection in the overall population undergoing EVAR was found to be between 0.2 % and 8 %, with an incidence at 25 months of 0.6 % [7]. The average timespan between EVAR surgery and infection is 28.3 months [8]. In our case, the patient presented with infection 17 months after EVAR, with first symptoms appearing within 24 h after the embolization procedure. Postoperative management of EL is a major concerning following EVAR. Type two endoleaks (EL2) are the most frequent.

Under these conditions, it is considered that an EL2 should be managed when the aneurysm has increased by more than 10 mm in diameter compared to the postoperative reference examination (class IIa and level C recommendation from the ESVS [9]). Several endovascular techniques and conversion to conventional surgery are described. The success rate ranges between 84 % and 100 % depending on the techniques. Complication rate is around 4 % for these procedures [10].

Mortality of aortic graft infection is significant, ranging from 20 % to 40 % [11] rising to 63 % without surgery. Several risk factors for infection after EVAR have been identified, including emergency procedures, perioperative complications or additional aortic procedures [7]. Patients usually have high white blood cell count, fever, and abdominal pain. In our case, the patient initially presented with fever. He later went on to present lower abdominal and sacral pain. Surprisingly, the patient never showed signs of severe sepsis and spontaneously improved.

The diagnosis in this case relied on a combination of blood culture identifying the pathogen, CT-angiography, and nuclear imaging. According to the latest ESVS guidelines [12], these tests confirm the presence of inflammation associated with infections. Infection can be diagnosed by white blood cell scintigraphy which detects accumulation of white blood cells over time. Its sensitivity stands at 90 % with a specificity of 88 % [13]. However, accuracy for infection localization is lower compared to PET CT, especially in the aortic region because of the elimination of the tracer by the digestive tract and absorption by the bone marrow. For these reasons, ESVS recommends PET CT for suspected aortic infections (class I and level B [9]). We opted for white blood cell scintigraphy due to its accessibility compared to long PET-CT delays at our institution. The patient's insidious clinical presentation without sepsis or signs of shock also led us to choose this examination over PET-CT. Common pathogens implicated in vascular graft infections include Staphylococcus aureus, Streptococci, or Pseudomonas aeruginosa [14]. Cutibacterium acnes is less common. This microorganism belongs to the Propionibacterium family, an anaerobic bacterium. This bacterium has been reported in shoulder prosthesis infections, cerebrovascular infections, fibrosis of breast implants, and endocarditis [15]. Cutibacterium acnes is a slow-growing organism with low virulence. In our case, infection and destruction of the aortic wall progressed rapidly. The injection of Lipiodol could have dispersed a significant inoculum directly into the aortic wall. We recommend examining the puncture site to potentially avoid a region with a macroscopically visible follicle. Additionally, it is conceivable that the aortic wall may become poorly vascularized after embolization and the infection spreads quicker in this excluded aneurysmal sac. For these reasons, less virulent pathogens may develop fast. Harry Etienne et al. [16] described a similar case to ours, with an EVAR infection by Cutibacterium acnes occurring 7 days after percutaneous embolization for EL2. They observed peri-aortic infiltration on day 9, followed by liquid collection on day 16. Inflammation was confirmed using PET-CT. In our case, the follow-up CT-angiography on day 10 confirmed infectious progression, despite our patient's favorable evolution. This case underscores the importance of repeated imaging in suspected VGI following embolization procedures. In another case report by Florian Dick et al. [17], two cases of aortitis following EVAR endoleak embolization were described. For the first case, the patient experienced abdominal pain, nausea, vomiting, and increased white blood cell count two days after the intervention. A CT-angiography performed at day 11 revealed an increase in the size of the aneurysmal sac. They undertook emergent surgical intervention and blood cultures tested positive for Staphylococcus and Streptococcus. In their second case, a patient was readmitted 21 days after percutaneous embolization. The patient complained of pain in the iliac fossa and right buttock. A CT-angiography showed aortic wall thickening. Surgical specimens revealed the presence of Cutibacterium acnes in the operative sites. The clinical course of these patients is similar to ours, with signs of infection identified on the CT-angiography between 10- and 20-days post-procedure. In our hospital, percutaneous trans-lumbar embolization is done by the interventional radiology team. Embolization is performed under local anaesthesia, guided by CT scan.

The diagnosis of endograft infection necessitates conversion to open surgery, with removal of the infected graft and reconstruction [18]. Extra-anatomic reconstruction could be accomplished with axillobifemoral bypass. This option avoids reintroducing foreign tissue into the infected area. In-situ reconstruction is also well-described. It can be performed using autologous superficial femoral veins. Cryopreserved allografts have a low reinfection rate, but tissue degradation over time necessitates additional intervention, with rates up to 55 % at 5 years [19]. New prosthetic material must be protected by rifampicin or silver-coated materials. Management of endograft infections require a multidisciplinary approach, and close collaboration with infectious disease specialists for targeted antibiotic therapy that may be continued for several weeks. We are mindful that our experience cannot be generalized. Larger studies need to be carried out on this complication to identify the best treatment.

4 Conclusion

We report a rare case of early infection of an aortic endoprosthesis following embolization of an EL. The identified microorganism is known to be low-virulent. White blood cell scintigraphy and repeat CT-angiography played crucial roles in establishing a definitive diagnosis. Despite favorable clinical and biological evolution, the patient developed a severe infection at the surgical intervention site. Therefore, caution is warranted when suspecting aortic endoprosthesis infection, necessitating close follow-up. More large series are required to have solid data and conclusions. This work was made possible with the help of the Fondation Mont Godinne.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
==== Refs
References

1 Siribumrungwong B. Kurita J. Ueda T. Outcomes of abdominal aortic aneurysm repairs: endovascular vs open surgical repairs Asian J. Surg. 45 1 Jan 2022 346 352 10.1016/j.asjsur.2021.06.015 (Epub 2021 Jun 27. PMID: 34193387) 34193387
2 EVAR trial participants Endovascular aneurysm repair vs. open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised control trial Lancet 365 2005 2179 2186 15978925
3 De Bruin J.L. Baas A.F. Buth J. DREAM Study Group Longterm outcome of open or endovascular repair of abdominal aortic aneurysm N. Engl. J. Med. 362 2010 1881 1889 20484396
4 Higashiura W. Greenberg R.K. Katz E. Predictive factors, morphologic effects, and proposed treatment paradigm for type II endoleaks after repair of infrarenal abdominal aortic aneurysms J. Vasc. Intervent. Rad. 18 2007 975 981
5 Hobbs S.D. Kumar S. Gilling-Smith G.L. Epidemiology and diagnosis of endograft infection J. Cardiovasc. Surg. 51 2010 5 14 20081758
6 Sohrabi C. Mathew G. Maria N. Kerwan A. Franchi T. Agha R.A. The SCARE 2023 guideline: updating consensus Surgical CAse REport (SCARE) guidelines Int. J. Surg. Lond. Engl. 109 5 2023 1136
7 Argyriou C. Georgiadis G.S. Lazarides M.K. Endograft infection after endovascular abdominal aortic aneurysm repair: a systematic review and meta-analysis J. Endovasc. Ther. 24 5 Oct 2017 688 697 28756719
8 Fernandez Prendes C. Riedemann Wistuba M. Zanabili Al-Sibbai A.A. Infrarenal aortic endograft infection: a single-center experience Vasc. Endovasc. Surg. 53 2019 132 138
9 Wanhainen A. Van Herzeele I. Bastos Goncalves F. Clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms Eur. J. Vasc. Endovasc. Surg. 67 2024 192 331 38307694
10 Ultee K.H.J. Büttner S. Huurman R. Editor’s choice e systematic review and meta-analysis of the outcome of treatment for type II endoleak following endovascular aneurysm repair Eur. J. Vasc. Endovasc. Surg. 56 2018 794 807 30104089
11 Vogel T.R. Symons R. Flum D.R. The incidence and factors associated with graft infection after aortic aneurysm repair J. Vasc. Surg. 47 2008 264 269 18241747
12 Chakfé N. Diener H. Lejay A. Clinical practice guidelines on the management of vascular graft and endograft infections Eur. J. Vasc. Endovasc. Surg. 59 3 2020 339 384 32035742
13 Reinders Folmer E.I. Von Meijenfeldt G.C.I. Van der Laan M.J. Diagnosis imaging in vascular graft infection: a systematic review and meta-analysis Eur. J. Vasc. Endovasc. Surg. 56 2018 719 729 30122333
14 Gavali H. Mani K. Furebring M. 315 treatment of abdominal aortic graft and endograft infections comparing extra-anatomic bypass with in situ reconstruction: a nationwide multicentre study Eur. J. Vasc. Endovasc. Surg. 62 2021 918 926 34782231
15 Achermann Y. Goldstein E.J. Coenye T. Propionibacterium acnes: from commensal to opportunistic biofilmassociated implant pathogen Clin. Microbiol. Rev. 27 2014 419 440 24982315
16 Etienne H. Touma J. Becquemin J.P. Unusual acute onset of abdominal aortic endograft infection by propionibacterium acnes after coil embolization for type II endoleak Ann. Vasc. Surg. 35 2016 204 209
17 Dick F. Diehm N. Gerber M. Aortitis following percutaneous aortic side branch embolization prior to endovascular repair of infrarenal aortic aneurysm J. Endovasc. Ther. 14 2007 801 804 18052597
18 Ducasse E. Calisti A. Speziale F. Aortoiliac stent graft infection: current problems and management Ann. Vasc. Surg. 18 2004 521 526 15534730
19 Lejay A. Delay C. Girsowicz E. Cryopreserved cadaveric arterial allograft for arterial reconstruction in patients with prosthetic infection Eur. J. Vasc. Endovasc. Surg. 54 2017 636 644 28890027
