Bilateral Carotid Patch Infection occurring 12 years following endarterectomy.

Background: Carotid endarterectomy (CEA) is the most commonly used invasive procedure for treatment of carotid stenosis. Different methods are used to close the arteriotomy including primary closure and patch repair with a graft. Prosthetic patch infection is a rare but serious complication of patch closure, and we will present a unique case of carotid patch infection (CPI) 12 years after implantation. Case: Patient is 76-year-old male ex-smoker with history of bilateral CEA with Dacron patch closure 12 years prior to presentation. He had a left neck draining sinus one year prior to presentation that was treated by patch excision and ICA ligation. He presented to us one year later with a right neck draining sinus tract, reaching the carotid sheath on CT scan. Surgery was done under EEG and NIRS oximetry with shunting. Excision of the patch with the involved ICA was done. CCA to distal ICA bypass was done by a reversed GSV graft. Intraoperative cultures of the patch grew Staphylococcus species coagulase negative, so the patient was discharged on antibiotics for one month. The patient had early postoperative swallowing difficulty that resolved over six weeks but no other complications. Patient was followed-up every three months and he was doing well on one-year follow-up. Discussion: Carotid patch infection is a well-documented complication of CEA with a prevalence between 0.27% and 1%. It most commonly presents as a pseudoaneurysm, draining sinus or neck swelling. The highest incidence is during the first year after the operation, and especially within the first three months postop due to contamination or wound infections; however, late presentations such as our case are rare. Bacterial cultures are positive in around 80% of the cases, growing mostly gram-positive cocci. Other organisms include Pseudomonas and Enterobacter. Management of CPI is challenging; difficulties include distal ICA control, friable arteries and adhesions to cranial nerves. Debridement with ligation of the vessel stump is an option, but may not be tolerated. Best outcomes are obtained with autogenous revascularization after debridement as was done in our case on the right side. Newer endovascular techniques may provide alternatives in urgent or high-risk situations, especially as staged procedures. This case is unique in its bilaterality and the longest time till presentation in the literature.