Ann Thorac Surg 1997;64:1810-1813
© 1997 The Society of Thoracic Surgeons
Case Report
Pseudomonas aeruginosa Coronary Stent Infection
François Bouchart, MD,
Arnaud Dubar, MD,
Jean Paul Bessou, MD,
Michel Redonnet, MD,
Jacques Berland, MD,
Dominique Mouton-Schleifer, MD,
Catherine Haas-Hubscher, MD,
Robert Soyer, MD
Departments of Thoracic and Cardiovascular Surgery and Anaesthesiology, Rouen University Hospital Charles Nicolle, and Department of Cardiology, Clinique Saint Hilaire, Rouen, France
Accepted for publication July 5, 1997.
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Abstract
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Stent infection is a rare complication of coronary angioplasty. We report a case of a coronary stent bacterial infection due to Pseudomonas aeruginosa, shortly after implantation of the stent in the left circumflex artery, which presented as an acute pericarditis. Surgical treatment consisted of stent removal and partial excision of the circumflex artery without coronary artery bypass grafting.
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Introduction
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Percutaneous transluminal coronary angioplasty (PTCA) is a well-established technique for the treatment of coronary artery disease. Results have been improved by the use of stents in terms of acute thrombosis and late restenosis [1, 2]. We report a rare complication of coronary stent implantation: coronary bacterial arteritis.
A 38-year-old nondiabetic man without any history of intravenous drug addiction presented with unstable angina treated by nitroglycerin, heparin, and a calcium-blocker. A coronary angiogram was performed, which revealed an occlusion of the circumflex artery (Fig 1
). The coronary pattern was of right dominance type. It was possible to reopen the artery and to insert a 20-mm Palmaz-Schatz coronary stent (PS 204; Johnson and Johnson Interventional Systems, Warren, NJ) during the same procedure (see Fig 1). The procedure was uneventful, taking less than 40 minutes. The immediate result was good, the arterial sheath was removed the next morning, and the patient was discharged 2 days after the procedure. No evidence of bacteremia was found during his stay.
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Fig 1. . Circumflex artery angiograms performed during the initial procedure. (A) Preangioplasty view: the circumflex artery was obliterated just distal to the first obtuse marginal branch. (B) The circumflex artery was opened and a Palmaz-Schatz was inserted with a good immediate angiographic result.
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Chest pain recurred on day 4 and echocardiographic examination showed only minimal pericardial effusion. On day 6, the patient's condition worsened with fever, chills, and increasing continuous chest pain. Blood cultures grew Pseudomonas aeruginosa. Urinalysis was negative and no line sepsis was found. Despite adapted antibiotic therapy, the patient's condition remained poor. A computed tomographic scan (Fig 2) showed contrast uptake around the stent in the left atrioventricular groove, moderate pericardial effusion, and left lower lobe consolidation. A new coronary angiogram (Fig 3) showed a false aneurysm in the area of the stent. An occlusion of the circumflex artery was observed just distal to the stent.
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Fig 2. . Computed tomographic scan showing contrast uptake in the left atrioventricular groove around the stent placed in the left circumflex artery. Moderate pericardial effusion is present.
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Fig 3. . Selective angiogram of the left circumflex artery showing the false aneurysm in the area of the infected stent. The circumflex artery is thrombosed just distal to the stent.
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An operation was carried out under emergency conditions. A small, purulent pericardial effusion was present. After institution of cardiopulmonary bypass and cold blood cardioplegia, the left atrioventricular groove was opened. A false aneurysm had developed from the lumen of the circumflex artery in the area of the stent, measuring 8 x 16 mm and filled with blood clots. The artery was partially ruptured and the stent was easily removed. Both the stent and the distal circumflex artery were thrombosed. The artery was ligated proximally and distally. All clots and the stent were cultured and grew Pseudomonas aeruginosa. No revascularization was performed. The patient was easily weaned from bypass, and the chest was closed in the usual manner. Septic hemodynamics was present for 8 hours postoperatively, requiring low-dose vasopressors, and the patient was weaned from the ventilator the following morning. The postoperative course was uneventful. Antibiotic therapy comprising ceftazidim and amikacin was maintained for 4 weeks. A routine echocardiogram before discharge on the 9th postoperative day showed no pericardial effusion and moderate lateral hypokinesia with good left ventricular function.
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Comment
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Percutaneous transluminal coronary angioplasty with a balloon catheter is an accepted and effective treatment for obstructive coronary artery disease. Intracoronary stents are useful tools to reduce the restenosis rate after coronary angioplasty [1]. Saito and colleagues [2] have shown a reduced rate of early complications and an improved 6-month outcome after primary stent placement for acute myocardial infarction. This procedure was chosen for the treatment of the circumflex artery acute thrombosis in our patient. Bredlau and co-workers, in their large series of 3,500 coronary artery angioplasties [3], did not report any major infectious complications, nor did other large series of stent implantations [1]. Most reported infectious complications after percutaneous transluminal coronary angioplasty were iliofemoral arteritis, usually described in case reports. Ten cases have been reported by Frazee and Flaherty [4] and 9 by McCready and associates [5], of which 18 were due to Staphylococcus aureus. Malanovski and colleagues [6], reviewing Staphylococcus aureus catheter-associated bacteremia, found a 0.25% risk after coronary angioplasty among 1,944 patients over a 25-month period. For these authors, the major risk factors for infection after angioplasty were a repeat percutaneous puncture of the same femoral artery, an indwelling arterial sheath that remained for several days especially where repeat catheterizations were performed through the same arterial sheath, and blood oozing around the arterial sheath causing hematoma. None of these predisposing factors was present in our patient. A prospective evaluation of the incidence of bacteremia after percutaneous transluminal coronary angioplasty was made by Shea and associates [7] on 164 consecutive patients. Bacterial isolates were recovered from 8% (23/286) of the blood cultures obtained via the arterial sheath (Staphylococcus epidermidis, 17/23). Fever developed in 4 patients and was procedure related in 1.
Central infectious complications are even less frequent. McCready and associates [5] reported 1 patient who had development of an aortic valve endocarditis and died. One aortic root abscess after right coronary artery angioplasty has been reported by Timsit coworkers [8]. This was due to Pseudomonas aeruginosa, as was the case in our patient. The patient did well after operation. Diabetes mellitus, a complex procedure, and a repeat procedure through the same arterial sheath were the risk factors found. A case of intracoronary stent-related bacterial arteritis was reported by Gunther and colleagues [9] in 1993. In their patient, an abcess developed at the site of implantation of the right coronary artery stent, associated with a pericardial empyema. The patient died despite aggressive surgical therapy comprising partial resection of the right coronary artery and distal right coronary artery bypass grafting. Our case was very similar, associating signs of bacterial pericarditis shortly after percutaneous transluminal coronary angioplasty with intracoronary stenting. The infection process around the stent resulted in partial destruction of the arterial wall and formation of a mycotic pseudoaneurysm and vessel occlusion.
We suggest that the surgical treatment should include removal of the foreign body, ie, the stent, and local debridement of all the infected tissues. This should include segmental resection of the artery. This, of course, raises the question of reestablishing coronary blood flow downstream from the lesion. In our case, the circumflex artery had a limited distribution and we preferred to avoid the risk of inserting a graft near the infected lesions.
Intracoronary stents are invaluable tools in the management of coronary stenosis, but infection can occur around the intravascular prosthesis, resulting in vessel thrombosis and pericarditis. A strict, surgically sterile procedure must be used in the insertion of endovascular stents similar to the procedures used for the placement of other prostheses. Multiple repeat procedure through the same arterial sheath should be avoided, and the arterial sheath should be removed as soon as possible.
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Acknowledgments
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We thank Mr Richard Medeiros for his advice in editing the manuscript.
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Footnotes
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Address reprint requests to Dr Bouchart, Department of Thoracic and Cardiovascular Surgery, Hôpital Ch Nicolle, 1, rue de Germont, F76031 Rouen, France (e-mail: Robert.Soyer{at}chu-rouen.fr).
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References
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- Serruys PW, De Jaegere P, Kiemeneij F, et al. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. N Engl J Med 1994;331:489–95.[Abstract/Free Full Text]
- Saito S, Hosokawa G, Kim K, Tanaka S, Miyake S. Primary stent implantation without Coumadin in acute myocardial infarction. J Am Coll Cardiol 1996;28:74–81.[Abstract]
- Bredlau CE, Roubin GS, Leimbruger PP, Douglas JS, King SB III, Gruentzig AR. In-hospital morbidity and mortality in patients undergoing elective coronary angioplasty. Circulation 1985;72:1044–52.[Abstract/Free Full Text]
- Frazee BW, Flaherty JP. Septic endarteritis of the femoral artery following angioplasty. Rev Infect Dis 1991;13:620–3.[Medline]
- McCready RA, Siderys H, Pittman JN, et al. Septic complications after cardiac catheterization and percutaneous transluminal coronary angioplasty. J Vasc Surg 1991;14:170–4.[Medline]
- Malanovski GJ, Samore MH, Pefanis A, Karchmer AW. Staphylococcus aureus catheter-associated bacteremia. Minimal effective therapy and unusual infectious complications associated with arterial sheath catheters. Arch Intern Med 1995;155:1161–6.[Abstract/Free Full Text]
- Shea KW, Schwartz RK, Gambino AT, Marzo KP, Cunha BA. Bacteremia associated with percutaneous transluminal coronary angioplasty. Cathet Cardiovasc Diagn 1995;36:5–9.[Medline]
- Timsit JF, Wolff MA, Bedos JP, Lucet JC, Decre D. Cardiac abscess following percutaneous transluminal coronary angioplasty. Chest 1993;103:639–41.[Abstract/Free Full Text]
- Gunther HU, Strupp G, Volmar J, von Korn H, Bonzel T, Stegmann T. Koronare Stentimplantation: Infektion und Abszedierung mit letalem Ausgang. Z Kardiol 1993;82:521–5.[Medline]
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Abstract
Introduction
