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Management of the Infected Carotid Artery Patch
It is likely that everyone performing carotid endarterectomy (CEA) is aware of prosthetic patch infection, but only 123 cases have been reported in the world literature from 29 published series (18 of which reported a single case). Accordingly, because surgeons only tend to publish good outcomes, it is likely that the procedural risks and longer-term rates of reinfection (or other adverse outcomes) may be considerably underestimated. This should be borne in mind when interpreting discussions on this subject.
The majority of vascular surgeons use patches either selectively or routinely, and many prefer to use prosthetic patches because they are accessible and because using them avoids groin wound complications and retains the long saphenous vein for future use. Unfortunately, prosthetic carotid patches are vulnerable to infection. The true prevalence of patch infection is unknown, but it is likely to be 1% or less.
Infecting Microorganisms
Out of the 123 patients known to have patch infection, 11 (9%) had no mention of whether a culture had been taken. Of the 112 where a culture was reported, 25 (20%) had no growth, and 87 (71%) yielded a positive growth for Staphylococcus sp. ( n = 79, 91%), Streptococcus sp., Bacteroides sp. ( n = 3, 2%), Pseudomonas sp. ( n = 3, 2%), and Proteus sp. (in the remaining patient). Overall, 11 patients culturing staphylococci (16%) grew methicillin-resistant Staphylococcus aureus (MRSA), and overall, 91% of all positive cultures grew either staphylococci or streptococci.
Clinical Presentation
There was a biomodal pattern of symptoms in the 123 patients with patch infection ( Table 1 ). Thirty-six patients (29%) presented within 2 months of their primary CEA, and 78 (63%) presented after 6 months or more had elapsed. Patients presenting within 2 months were more likely to present with an abscess or complex wound infection (20/36, 56%) or patch rupture (6/36, 17%). A minority presented with false aneurysm formation (3/36, 8%). By contrast, patients presenting after more than 6 months had elapsed since their CEA were significantly more likely to present with false aneurysm (22/78, 28%) or chronic sinus discharge (28/78, 36%) and were unlikely to present with either a wound abscess (12/78, 15%) or patch rupture (6/78, 8%). Overall, only four of the 123 patients (3%) presented with either a transient ischemic attack (TIA) or stroke.
TABLE 1
Mode of Presentation of 75 Cases of Prosthetic Patch Infection Relative to Timing after Surgery
| Lesion | <2 mo | 2–6 mo | >6 mo | Total |
|---|---|---|---|---|
| Wound infection or abscess | 20 | 1 | 12 | 33 |
| Patch rupture | 6 | 1 | 6 | 13 |
| False aneurysm | 3 | 2 | 22 | 27 |
| Sinus discharge | 6 | 3 | 28 | 37 ∗ |
| Sinus + false aneurysm | 0 | 2 | 6 | 8 |
| TIA/stroke | 1 | 0 | 1 | 2 † |
| Swelling | 0 | 0 | 0 | 3 |
| Total | 36 | 9 | 78 | 123 |
TIA , Transient ischemic attack.
∗ Two of these patients presented with TIA as well.
† Paper did not specify any other presentation but recorded positive cultures.
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