Fatal Acute Limb Ischemia Due to Catastrophic Late Endograft Infection and Adjacent Arterial Infection After Endovascular Aneurysm Repair – A Case Report

Abstract

Teguh Marfen Djajakusumah,1 Putie Hapsari,1 Birgitta Maria Dewayani,2 Jackie Pei Ho,3 Herry Herman,4 Kiki Lukman,5 Ronny Lesmana6 1Division of Vascular and Endovascular Surgery, Department of Surgery, Universitas Padjadjaran – Hasan Sadikin Hospital, Bandung, Indonesia; 2Department of Pathology, Universitas Padjadjaran – Hasan Sadikin Hospital, Bandung, Indonesia; 3Department of Surgery, National University of Singapore, Singapore; 4Department of Orthopaedic Surgery, Universitas Padjadjaran – Hasan Sadikin Hospital, Bandung, Indonesia; 5Department of Surgery, Universitas Padjadjaran – Hasan Sadikin Hospital, Bandung, Indonesia; 6Department of Physiology, Universitas Padjadjaran, Bandung, IndonesiaCorrespondence: Teguh Marfen Djajakusumah, Email [email protected]: We present a case of late endograft infection that progressed to the left iliac and femoral arteries, leading to left lower extremity gangrene, and the patient’s death.Case: A 65-year-old male with a history of endovascular abdominal aortic aneurysm repair (EVAR) developed left acute limb ischemia (Rutherford category III) and abdominal pain. A CT scan showed significant gas formation around the endograft and complete occlusion of the left distal iliac artery to the femoral arteries. Despite undergoing hip disarticulation and wound care, aortic endograft removal was not possible due to a lack of replacement grafts. Microbiological cultures from arterial pus and urine identified multiple antibiotic-resistant extended-spectrum beta-lactamases (ESBL) producing Escherichia coli. Histopathological analysis of the common femoral artery specimen indicated chronic medium-sized arteritis characterized by endothelial erosion, fibrotic myocytes in the tunica media, and fibrosis of the adventitial layer with inflammatory cell infiltration. The patient succumbed in the ICU 6 days later due to uncontrolled sepsis.Discussion: Although the incidence of endograft infection after EVAR is low (20– 75% morbidity and mortality), it poses significant risks. Sources are often hematogenous, stemming from urinary or respiratory tract infections, and infections extending to subsequent arteries are very rare; they could cause chronic arterial inflammation and, in the long term, may lead to thrombosis and limb ischemia. This case highlights a low-grade infection that emerged 3 months post-procedure. Diagnosis typically involves CT angiography to detect periaortic gas or fluid. Management of high-grade infections necessitates complete endograft removal and graft replacement with infection-resistant options.Conclusion: Endograft infections after EVAR, while rare, can have severe outcomes. Early diagnosis based on symptoms and CT-Scan. In high-grade infections, endograft removal is the gold-standard therapy, with ongoing follow-up post-EVAR being essential for prevention.Plain Language Summary: Late stent-graft infection after minimal invasive surgery for aneurysm, which causes acute limb ischemia, is very rare and can spread to subsequent arteries (contiguous arterial infection).Infection of the stent-graft may cause blood vessel obstruction originated from infection.Marfen et al reported that the infected artery is a true vasculitis, with pathological findings showing chronic arteritis with antibiotic resistant Escherichia coli as the cause of stent-graft infection being very rare, and reports are scarce.The stent-graft in a severe stent-graft infection MUST be removed to control the infection.Keywords: arteritis, case report, endograft infection, ESBL, graft removal

Keywords

• arteritis
• case report
• endograft infection
• esbl
• graft removal