Bare Metal Stent Infection: Case Report and Literature Review

Abstract

A 75 year old female who previously underwent subclavian artery bare metal stenting presented with hemoptysis, left chest, neck and back pain. A computed tomography angiogram revealed a dissected left subclavian artery with migration and perforation of previously placed bare metal stents and hemopneumothorax, which suggested a large abscess formation. Stabilization of the dissected subclavian artery was done with placement of an 8×38 mm covered endovascular stent. Ultimately, a thoracotomy was done for investigation of a suspected abscess and infected stents. Cultures taken from both free fluid and center of abscess cultivated Staphylococus aureus and Peptostreotpcoccus prevotii. Perioperative bronchoscopy and esophagogastroduodenoscopy ruled out a Broncial fistula formation. The patient was ultimately transferred to a tertiary care facility for evaluation of subclavian bypass and removal of the infected devices. Given the large increase in percutaneous procedures, it would be expected that endovascular device infection would also rise; however, few cases have been reported as research on this topic is difficult to undertake. High clinical suspicion is usually needed to make the diagnosis of infected endovascular devices. The detection of infected endovascular devices is often found with incidental imaging procedures. The most commonly cultivated bacterium in infected stents has been Staphylococcus species. Treatment of endovascular device infections mirrors that of traditional surgical graft infections with removal of infected hardware. This case report adds to the body of evidence in regards to infected endovascular devices, which are relatively uncommon, seldom researched, and hard to diagnose without significant suspicion or incidental findings on imaging.Keywords: Infection; Bare Metal; Stent; Endovascular; Device Case DescriptionA 75 year old female who recently had proximal subclavian stenting with two bare metal stents to alleviate severe debilitating left upper extremity claudication. One-week post procedure, the patient began to have left chest, neck and back pain. After developing scant hemoptysis, she presented to the emergency department severely anemic and hypotensive. An immediate computed tomography angiogram was done to evaluate the status of her previously placed subclavian stents. The computed tomography angiogram revealed 6 mm gap between the two stents within the left subclavian artery (Figure 1 and 2). There was also a pooling of contrast-enhanced blood at the level of the gap with a small extravasation of contrast along the lateral aspect, indicating an active bleed. Furthermore, a large mixture of blood and gas was noted in the left upper mediastinum. No clear communication existed between the tracheo-bronchial tree or esophagus and the fluid collection. A left subclavian artery dissection was noted that began at the distal aspect of the distal stent and extended through the left axillary artery into the left brachial artery.Interventional cardiology was contacted and the patient ...