Peripheral prosthetic vascular graft infection following lower limb surgical revascularization is a relatively rare but serious condition. A case of early infection and occlusion of a above-knee femoro-popliteal artery prosthetic bypass is here reported. It was accompanied by acute lower limb ischemia, fever and distally by embolic septic skin lesions

BENEDETTO, FILIPPO

CASCIO, Antonio

DE CARIDI, Giovanni

LENTINI, SALVATORE

MASSARA, MAFALDA

SPINELLI, Francesco

English

Archivio istituzionale della ricerca - Università di Palermo

SEPTIC SKIN LESIONS: AN UNCOMMON MANIFESTATION OF PERIPHERAL PROSTHETICVASCULAR GRAFT INFECTION MAFALDA MASSARA1, ANTONIO CASCIO2, FILIPPO BENEDETTO1, GIOVANNI DE CARIDI1, SALVATORE LENTINI3, FRANCESCOSPINELLI11Cardiovascular and Thoracic Department, University of Messina, Messina - 2Department of Human Pathology, University of Messina,Messina - 3Cardiovascular Department, Città di Lecce Hospital, Lecce, ItalyIntroductionInfection of a prosthesis following a lowerlimb surgical revascularization is a relatively rarecondition (1-6%)(1). Serious complications canoccur, such as pseudoaneurysm formation at thelevel of anastomotic site, bleeding, graft occlusionand organ failure, resulting in leg amputation(10–70%) or even death (10-20%)(2-5). Among thecomplications, septic skin lesions are very rare andonly a few cases are reported in literature(6, 7).Here we describe a case of early infection andocclusion of a femoro-popliteal above the kneeprosthetic bypass, that was accompanied by acutelower limb ischemia, fever and distally by embolicseptic skin lesions. Current literature on this subjectis reviewed.Case presentationA 71 years old woman affected by systemichypertension and type II diabetes with a history ofperipheral artery disease previously treated by per-cutaneous transluminal angioplasty (PTA) cameunder our observation complaining of right lowerlimb rest pain (stage 4 of Rutherford classification).Ultrasound (US) Doppler scan showed sub-occlusive re-stenosis of the right superficial femoralartery (SFA) previously treated with PTA, patency ofthe popliteal artery and patency of two tibial vessels(peroneal and posterior tibial artery). A femoro-popliteal above the knee bypass was performed usinga vascular graft in polytetrafluoroethylene (PTFE).During hospitalization the patient received perioper-ative antibiotic prophylaxis with cefazolin and lowmolecular weight heparin therapy (LMWH). Shewas discharged home on the 8th postoperative dayon  LMWH and antiplatelet therapy.The patient returned to our observation twentydays later appearing seriously ill. On admission shehad right lower limb acute pain, fever (38.5 °C),pulse rate 110 beats/min, respiratory rate 22breaths/min, blood pressure 90/60 mmHg and oxy-gen saturation 88%. The right lower limb waspainful with foot cyanosis and dehiscence of thedistal surgical wound, with necrosis of skin mar-gins. On the right leg there were also peculiar skinlesions suggestive of peripheral embolism. In par-ticular, several erythematous plaques with a pur-puric center and poorly defined borders were pre-sent (Figure 1).Acta Medica Mediterranea, 2014, 30: 651ABSTRACTPeripheral prosthetic vascular graft infection following lower limb surgical revascularization is a relatively rare but seriouscondition. A case of early infection and occlusion of a above-knee femoro-popliteal artery prosthetic bypass is here reported. It wasaccompanied by acute lower limb ischemia, fever and distally by embolic septic skin lesions. Key words: Embolism; infection; skin; vascular graft.Received February 18, 2014; Accepted March 24, 2014They were mostly present on the distal portionof the limb where they tended to be present in clus-ters. US scan confirmed prosthetic bypass occlusionas the cause of acute limb ischemia. Neither arterialaneurysms with ulcerated atherosclerotic plaquesnor pseudo-aneurysm sources of emboli were iden-tified through physical examination or US scan.Electrocardiography excluded ischemic myocardialabnormalities or arrhythmias; echocardiographyrevealed normal ventricular function with no car-diac valves vegetations or other sources of cardiacemboli. Laboratory investigations revealed a whiteblood cell count (WBC) of 15.500/mm3 (76% neu-trophils); C-reactive protein (CRP) 30 mg/dL (nor-mal values < 0.5 mg/dL), increased serum potassi-um, lactate dehydrogenase and creatine kinase; theremainder of blood results including clottingscreening were within normal ranges. Two samples for blood cultures were drawn.Broad spectrum antibiotic therapy with teicoplaninand levofloxacin was started and the patient wasbrought to the surgical room. A femoro-tibial per-oneal trunk bypass using the great saphenous veinin situ was performed. Surgical decompression ofthe anterior leg compartment was also completed toavoid compartment syndrome after revasculariza-tion. In the suspicion of a prosthetic infection,based on the fact that the prosthesis appeared notwell adherent to the surrounding tissues, the PTFEpreviously implanted prosthesis was removed andsent for microbiological analysis; a drainage waspositioned in correspondence of the previous distalsurgical wound.Histopathology of the skin lesions showed anormal epidermis and multifocal, dense neu-trophilic inflammatory infiltrates in the mid anddeep dermis with extravasated red blood cells. Thevessels presented a prominent endothelium, intralu-minal thrombi, and intraluminal, intraparietal, andinterstitial neutrophils.The microbiological cultures from theremoved thrombus and prosthesis returned positivefor Staphylococcus warneri; the strain was resistantto methicillin, erythromycin, clindamycin, and sen-sitive to teicoplanin (MIC≤0.5µg/ml), linezolid(MIC≤1µg/ml) and tetracycline (MIC≤4µg/ml).Levofloxacin was stopped and teicoplanin contin-ued for a total of 10 days. General conditions slow-ly improved with normalization of the WBC countand CRP value. The right lower limb conditionsimproved with disappearance of the distal cyanosis,resumption of normal local temperature and nor-malization of both motility and sensitivity. Thepatient was discharged home on the 15th postopera-tive day without signs or symptoms of infection. At1, 3, 6, and 12 month follow-up visits, US scanexam showed the patency of the femoro-distalbypass and absence of local and systemic signs andsymptoms of infection.DiscussionInfection of a prosthesis following a lowerlimb surgical revascularization is a relatively rarebut serious complication. The appearance of periph-eral septic skin lesions is an uncommon and veryrare manifestation of this condition. To the best ofour knowledge, only two cases of peripheral septicskin lesions originating from an infected peripheralvascular prosthesis have been previously reportedin literature. Zumelzu et al. described a case offever, purpura of the left lower limb with cyanoticleft toes in a 43 year-old-HIV-positive man present-ing a voluminous right iliac abscess, following acrossover iliofemoral arterial bypass. The patientwas submitted to skin biopsy, blood culture,echocardiography to exclude a cardiac source ofperipheral septic embolism, bypass eco-color-duplex, ankle radiograph and abdominal and pelvicCT scan, demonstrating a periprosthetic abscess.Treatment was based on surgical debridement of theabscess without prosthesis removal and specificantibiotic therapy (oxacillin for 6 months), resultingin complete healing(6).Boureau et al. reported a case of late infectionof an iliofemoral prosthetic vascular graft in a 52year-old man, accompanied by purpura localized onthe right leg and fever. Also in this case the diagno-sis was achieved through skin biopsy, echocardiog-raphy and blood culture. A specific antibiotic thera-652 Mafalda Massara, Antonio Cascio et AlFigure 1: Erythematous plaques with a purpuric centerand poorly defined borders on the distal part of the rightlower limb.py was started (penicillin and gentamycin), theinfected prosthesis was removed and an extra-anatomic bypass was performed, to avoid the lowerlimb ischemia. Also in this patient a complete heal-ing was observed(7).In both cases the infection was caused byStaphylococcus aureus, while in our patient thegerm involved was Staphylococcus warneri. Ourpatient presented an early infection with conse-quently occlusion of a femoro-popliteal above theknee prosthetic bypass. Unlike the other two cases,our patient was a 71 year-old woman that presentedalso an acute ischemia of the lower limb, in addi-tion to fever and peripheral septic skin lesions.The diagnosis was obtained through skin biop-sy, blood culture and echocardiography, to excludea cardiac source of emboli. The treatment wasbased on antibiotic therapy (teicoplanin), removalof the infected prosthesis as reported by Boureauand co-workers and, unlike the two cases men-tioned, a femoro-tibial peroneal trunk bypass usingthe great saphenous vein was performed. In addi-tion, our patient required surgical decompression ofthe anterior leg compartment to avoid compartmentsyndrome after revascularization. As in the othercases, the healing of the patient was obtained.Staphylococci (S. aureus and coagulase-nega-tive staphylococci) account for 80% of prostheticvascular graft infections(8), but infections caused byfungi (mainly Candida), other Gram-positive cocci(enterococci, streptococci), or Gram-negative rods(mainly Eschericha coli, Pseudomonas aeruginosaand Klebsiella spp.) are also reported(9).Possible causes of PVGI are represented bylocal bleeding and haematoma formation aroundthe prosthesis that could be responsible also ofbypass compression and occlusion; cutaneousnecrosis caused by prolonged skin margin retractionor subcutaneous tangential inappropriate dissectionduring surgery and lymphorrhea.The clinical presentation of PVGI is very vari-able. Early infections that develop less than 3months after surgery, generally occur with acuteonset of fever, bacteraemia, pain, erythema,swelling, warmth, local bleeding, graft occlusion orthe appearance of a pulsatile mass, sign of pseudoa-neurysm formation. Late infections develop morethan 3 months after surgery: systemic manifesta-tions of infection are often absent and blood cul-tures are often negative.Clinically, they may present with more subtlesymptoms and signs such as back pain, fistula, graftocclusion and asymptomatic pseudoaneurysm for-mation(10).The presence of peripheral septic skin lesionsrepresents a very uncommon clinical manifestationof this condition, therefore the differential diagnosiswith other sources of septic embolism is alwaysrequired. In particular, peripheral septic cutaneousmanifestations generally have a cardiac source suchas endocarditis and echocardiography is required toachieve a correct diagnosis. Non-cardiac sources ofseptic skin lesions are more rarely observed andactually, the most frequent cause of these could berepresented by arterial pseudoaneurysm formationand/or septic endarteritis following percutaneoustransluminal angioplasty; this is due to the increas-ing use of invasive diagnostic and therapeutic vas-cular procedures(11-15).The diagnosis is essentially based on clinicalexamination of the patient, skin biopsy of thelesions, microbiological exam of the removed pros-thesis and blood culture. Echocardiography is use-ful to exclude a cardiac source of septic emboli.In conclusion, our case provides clinical evi-dence to add septic skin embolism among the com-plications of peripheral prosthetic revascularization.Physicians should be aware that patients presentingwith fever and purpuric lesions on the skin distallyto a prosthetic bypass may have septic embolismand include this in their differential diagnosis.Apart the intervention of revascularization and sur-gical debridement of the infected tissues, it is essen-tial to perform blood cultures, cultures of thethrombus and of the removed prosthesis. Antibiotictherapy should not be delayed, broad spectrumempiric antibiotics should be used initially, and onthe basis of culture results should be subsequentlytailored.References1) Darouiche RO Treatment of infections associated withsurgical implants. N Engl J Med 2004; 350: 1422-1429.2) Edwards WH, Jr., Martin RS, 3rd, Jenkins JM,Edwards WH, Sr., Mulherin JL, Jr. Primary graft infec-tions. J Vasc Surg 1987; 6: 235-239.3) Calligaro KD, Veith FJ, Schwartz ML, et al. Selectivepreservation of infected prosthetic arterial grafts.Analysis of a 20-year experience with 120 extracavi-tary-infected grafts. Ann Surg 1994; 220: 461-469; dis-cussion 469-471.4) Liekweg WG, Jr., Greenfield LJ Vascular prostheticinfections: collected experience and results of treat-Septic skin lesions: an uncommon manifestation of peripheral prosthetic vascular graft infection 653ment. Surgery 1977; 81: 335-342.5) Newington DP, Houghton PW, Baird RN, Horrocks MGroin wound infection after arterial surgery. Br J Surg1991; 78: 617-619.6) Zumelzu C, Alexandre M, Blom A, et al. Unilateralpurpura of a limb revealing a periprosthetic abscess inan HIV-infected patient. Ann Dermatol Venereol 2011;138: 748-752.7) Boureau AS, Lescalie F, Cassagnau E, Clairand R,Connault J Localized purpura revealing vascular pros-thetic graft infection. J Mal Vasc 2013; 38: 276-279.8) Stone PA, Back MR, Armstrong PA, et al. Evolvingmicrobiology and treatment of extracavitary prostheticgraft infections. Vasc Endovascular Surg 2008; 42:537-544.9) Mayer D, Hasse B, Koelliker J, et al. Long-term resultsof vascular graft and artery preserving treatment withnegative pressure wound therapy in Szilagyi grade IIIinfections justify a paradigm shift. Ann Surg 2011; 254:754-759; discussion 760.10) Hasse B, Husmann L, Zinkernagel A, et al. Vasculargraft infections. Swiss Med Wkly 2013; 143: w13754.11) Sanz-Canalejas L, Floristan-Muruzabal U, Feito-Rodriguez M, et al. [Septic emboli to the skin follow-ing angioplasty]. Actas Dermosifiliogr 2011; 102: 142-145.12) Izumi AK, Samlaska CP, Hew DW, Bruno PP Septicembolization arising from infected pseudoaneurysmsfollowing percutaneous transluminal coronary angio-plasty: a report of 2 cases and review of the literature.Cutis 2000; 66: 447-452.13) Evans BH, Goldstein EJ Increased risk of infectionafter repeat percutaneous transluminal coronary angio-plasty. Am J Infect Control 1987; 15: 125-126.14) McCready RA, Siderys H, Pittman JN, et al. Septiccomplications after cardiac catheterization and percu-taneous transluminal coronary angioplasty. J VascSurg 1991; 14: 170-174.15) Krupski WC, Pogany A, Effeney DJ Septic endarteritisafter percutaneous transluminal angioplasty. Surgery1985; 98: 359-362.Funding acknowledgment statementThis research received no specific grant from any fundingagency in the public, commercial, or not-for-profit sectors._________Request reprints from:PROF. ANTONIO CASCIOUOC Malattie Infettive, AOU Policlinico “G. Martino”Via Consolare Valeria n. 198125 Messina(Italy)654 Mafalda Massara, Antonio Cascio et Al

Septic skin lesions: an uncommon manifestation of peripheral prosthetic vascular graft infection

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Septic skin lesions: an uncommon manifestation of peripheral prosthetic vascular graft infection

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