Open Surgical Conversion of Popliteal Endograft Infection: Case Reports and Literature Review

Abstract

Background: Endovascular treatment of popliteal aneurysms (PA) has increased in the last few years, quickly becoming the main treatment performed in many vascular centers, based on the acceptable and promising outcomes reported in the literature. However, endograft infections after endovascular popliteal aneurysm repair (EPAR) are the most dangerous complications to occur as they involve serious local compromise and usually require open surgical conversion and device explantation to preserve the affected extremity.

Case report: We report two patients who were admitted to the emergency room of our hospital for pain and edema in the lower leg. Both patients had undergone exclusion of a ruptured PA a few years before by endovascular graft. CTA testing showed a significant volume of fluid-corpuscular collection related to perianeurysmal abscess collection in both cases. Blood cultures and drained material cultures were positive for Staphylococcus capitis in the first case and S. aureus in the second. Prophylactic antibiotics were administered for 10 days, then patients underwent an open surgical conversion with the complete explantation of endovascular material and a femoro-popliteal bypass using an autologous vein in the first case and a biological bovine pericardium prosthesis in the second case. The infective department of our hospital had defined a discharged specific antibiotic therapy for each patient, based on intraoperative microbiological samples. Furthermore, we have examined the literature and found six more cases described in case report articles that refer to popliteal graft infections by different microorganisms, mostly presenting acute limb ischemia as the first symptom and suggesting endograft explantation with open conversion and autologous vein bypass as the commonest therapeutic choice.

Conclusions: The open surgical conversion of popliteal endograft infection is the best strategy to manage peripheral infection after an endovascular popliteal aneurysm repair procedure.

Keywords: endograft infection; open surgical conversion; popliteal aneurysm; popliteal endograft infection.

Figure 1

(a) Preoperative CTA, showing the ruptured PAA in the lateral projection and a focal rupture in the rectus femoris muscle in the axial projection in the yellow box marked by narrowing. (b) Final intraoperative radiographic control showing the VIABAHN™ endoprosthesis and Supera stent in the popliteal artery after the first endovascular emergency procedure. (c) An intraoperative angiography through the catheter shows proximal and (d) distal intrastent thrombosis. (e) Intraoperative complication with thrombosis of the anterior tibial artery and peroneal trunk. (f) Computer tomography angiography shows a perianeurysmal collection of approximately 9 cm and endovascular bypass patency.

Figure 1

(a) Preoperative CTA, showing the ruptured PAA in the lateral projection and a focal rupture in the rectus femoris muscle in the axial projection in the yellow box marked by narrowing. (b) Final intraoperative radiographic control showing the VIABAHN™ endoprosthesis and Supera stent in the popliteal artery after the first endovascular emergency procedure. (c) An intraoperative angiography through the catheter shows proximal and (d) distal intrastent thrombosis. (e) Intraoperative complication with thrombosis of the anterior tibial artery and peroneal trunk. (f) Computer tomography angiography shows a perianeurysmal collection of approximately 9 cm and endovascular bypass patency.

Figure 2

(a) Intraoperative section of medial tight access, revealing the wall of an intact aneurysmal collection. (b) Infected material (VIABAHN™ endoprosthesis) in the opened sac, with the infected graft lying inside. (c) Intraoperative stent graft: explanted materials. (d) Femoropopliteal bypass with the autologous reversed vein.

Figure 3

(a) CTA images showing the popliteal collection surrounding the popliteal stent graft; (b) CTA images showing the popliteal endograft (arrows) and the ruptured collection in the femoral muscles (arrowheads).

Figure 4

The PRISMA chart identifies 114 articles as free PubMed research: of these, 6 full papers adequately described a popliteal infected stent graft.

Figure 5

Workflow of popliteal stent graft infection, as developed in our center. EPAR: endovascular PAA repair; CTA: computer tomography angiography; DUS: ultrasound exam; PET: positron emission tomography.