Long Term Outcome After EndoVAC Hybrid Repair of Carotid Patch Infection

Carotid patch infection is an uncommon but serious complication after carotid endarterectomy (CEA). Radical open surgical treatment with autologous vein reconstruction is recommended.1Naylor R. Rantner B. Ancetti S. de Borst G.J. De Carlo M. Halliday A. et al.Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease.Eur J Vasc Endovasc Surg. 2023; 65: 7-111Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar However, the risk of cranial nerve injury, stroke, and death is high, and in certain circumstances (ongoing bleeding, hostile anatomy, insufficient cerebral collaterals, comorbidities) radical surgical treatment may not be feasible. Then, the Endovascular Vaccum Assisted Closure (EndoVAC) hybrid technique may be considered, which consists of three steps (Fig. 1):1Naylor R. Rantner B. Ancetti S. de Borst G.J. De Carlo M. Halliday A. et al.Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease.Eur J Vasc Endovasc Surg. 2023; 65: 7-111Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar(1)Relining the infected area with self expanding stent grafts via a femoral approach, and concomitant coiling of the external carotid artery (ECA) if needed.(2)Explantation of the infected patch, with minimal exposure and without the need to clamp the vessel, and ligation of ECA when necessary.(3)VAC therapy (KCI Medical, San Antonio, TX, USA), with black polyurethane foam sponge applied directly on the vessel and the exposed stent graft, and continuous topical negative pressure during the first 24 hours followed by intermittent negative pressure of 125 mmHg to facilitate granulation and delayed secondary healing. Favourable early and midterm outcomes have been reported.2Thorbjørnsen K. Djavani Gidlund K. Björck M. Kragsterman B. Wanhainen A. Editor's Choice - Long-term outcome after EndoVAC hybrid repair of infected vascular reconstructions.Eur J Vasc Endovasc Surg. 2016; 51: 724-732Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar The aim of this study was to assess the outcomes of EndoVAC in an expanded cohort with longer follow up. Nine patients underwent the EndoVAC procedure for infected synthetic polyester carotid patches between November 2007 and February 2023, median age 73 years (range 65 – 80). Indications included ongoing bleeding (n = 4), previous re-operations (n = 2), insufficient cerebral collaterals (n = 1), and comorbidities (n = 9). Propionibacterium acnes (n = 2), Coagulase negative staphylococci (n = 4), and Pseudomonas aeruginosa (n = 1) were cultured in seven patients. Broad spectrum antibiotics were administered until wound cultures provided more information, for at least three months or until no signs of infection were observed. Individualised long term follow up continued until complete healing occurred, and included clinical examination, blood tests, carotid ultrasound, and 18-fluorodeoxyglucose (18-FDG) positron emission tomography combined with computed tomography (PET/CT) scanning. The primary technical success rate was 100% without 30 day mortality or cerebrovascular events. The median duration of VAC treatment was 17 days (range 13 – 94), and antibiotics were prescribed for a median of seven months (range 3 – 18). All patients were prescribed antithrombotic therapy at discharge (dual antiplatelet therapy [DAPT] with acetylsalicylic acid and clopidogrel [n = 4], clopidogrel with low dose apixaban [n = 1], monotherapy with acetylsalicylic acid [n = 2], and warfarin [n = 2]). Over a median clinical follow up of 7.6 years (range 0.2 – 13.8), all cases showed complete healing of the infection with no graft related re-infection. There were no signs of infection on 18-FDG-PET-CT in seven patients. Three patients (33%) died during follow up, not related to the EndoVAC procedure or infection. Carotid artery imaging follow up was available in eight patients after a median of 2.3 years (range 0.5 – 5.7) follow up. Two patients had re-interventions during follow up; one elective re-stenting due to asymptomatic in stent stenosis after 4.1 years, and one emergency thrombectomy and re-stenting due to acute stent graft occlusion after 3.5 years with residual aphasia, both were on DAPT. One patient with an in stent stenosis and on full anticoagulation occluded the stent graft after 1.3 years, without any permanent neurological symptoms. This report showed no signs of re-infection after EndoVAC treatment of carotid patch infection, over 13 years follow up; however, the occlusion and re-intervention rates were high. Recent case reports have confirmed these findings.3Chan E. Bailey M. McPherson S. Wanhainen A. Scott D.J.A. Forsyth J. Carotid EndoVAC: a novel hybrid technique for carotid Dacron patch infection.J Vasc Soc GB Irel. 2023; 2: 182-185Google Scholar,4Wang K. Mohan I.V. Hybrid repair of infected carotid patch.Eur J Vasc Endovasc Surg. 2022; 63: 767Abstract Full Text Full Text PDF Scopus (1) Google Scholar A systematic review of patch infection after CEA, included eight of 171 infected carotid patches, that had been treated by stent grafting with promising results.5Wikkeling T.M. van Gijssel S.A. van der Laan M.J. Zeebregts C.J. Saleem B.R. Treatment of patch infection after carotid endarterectomy: a systematic review.Ann Transl Med. 2021; 9: 1213Crossref Google Scholar According to the European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Vascular Graft and Endograft Infections, endovascular treatment may be considered to gain control in life threatening haemorrhage or as a definitive treatment in severe comorbid patients,6Chakfé N. Diener H. Lejay A. Assadian O. Berard X. Caillon J. et al.Editor's Choice - European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Vascular Graft and Endograft Infections.Eur J Vasc Endovasc Surg. 2020; 59: 339-384Abstract Full Text Full Text PDF PubMed Scopus (253) Google Scholar which was reiterated by the recent ESVS 2023 Carotid Guidelines.1Naylor R. Rantner B. Ancetti S. de Borst G.J. De Carlo M. Halliday A. et al.Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease.Eur J Vasc Endovasc Surg. 2023; 65: 7-111Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar The implantation of an endovascular prosthesis is done in living tissue, as opposed to an open surgical reconstruction. This may contribute to an in situ antimicrobial coating of the prosthesis from the antibiotic saturated circulating blood. The negative pressure wound therapy removes microorganisms, inflammatory mediators, and performs mechanical cleaning, but also stimulates the healing process over the exposed stent graft. The observed high rate of late in stent stenosis, with risk of occlusion, suggests that these patients should be offered long term imaging surveillance, with a low threshold for re-intervention if patency is threatened. In addition, enhanced post-operative antithrombotic therapy should be considered. Due to the observed in stent stenosis despite DAPT, aspirin and low dose anticoagulation according to the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial regimen may be considered. This study is limited because it is a small retrospective single centre report, subject to selection and publication bias which may be offset by the long term follow up in all patients. Additional data to demonstrate the safety and efficacy of this EndoVAC technique are warranted, and we encourage colleagues to contact us to set up this registry. None.