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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 2  |  Issue : 2  |  Page : 115-117

Early detection of a potentially fatal complication of coronary stent implantation using transthoracic two-dimensional-echocardiography


Department of Cardiology, TNMC and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India

Date of Web Publication6-Sep-2018

Correspondence Address:
Dr. Rajendra Vishwambhar Chavan
Add: No. 18 ICCU, Department of Cardiology, Ground Floor OPD Building, OPP Casualty Department, TNMC and BYL Nair Charitable Hospital, Mumbai - 400 008, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_75_17

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  Abstract 

The number of coronary stent (CS) implantation has significantly increased since its introduction in 1987. CS infection is a rare but potentially fatal complication. No imaging modality is confirmatory for diagnosing CS infection. Positive blood cultures, two-dimensional-echocardiography (especially transesophageal echocardiography), transthoracic echocardiography (TTE), coronary angiography, computed tomography-scan, and magnetic resonance imaging are useful. We report a case of a 65-year-old male who presented within a month of CS implantation with high-grade fever and chest pain. TTE showed a localized collection in the right atrioventricular groove clinching the diagnosis to CS infection. The patient responded to higher doses of broad-spectrum antibiotics which were continued for 6 weeks.

Keywords: Atrioventricular groove collection, coronary stent infection, fever postpercutaneous transluminal coronary angioplasty, stent abscess


How to cite this article:
Nawale JM, Bedmutha KR, Chavan RV, Chaurasia AS. Early detection of a potentially fatal complication of coronary stent implantation using transthoracic two-dimensional-echocardiography. J Indian Acad Echocardiogr Cardiovasc Imaging 2018;2:115-7

How to cite this URL:
Nawale JM, Bedmutha KR, Chavan RV, Chaurasia AS. Early detection of a potentially fatal complication of coronary stent implantation using transthoracic two-dimensional-echocardiography. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2018 [cited 2018 Dec 13];2:115-7. Available from: http://www.jiaecho.org/text.asp?2018/2/2/115/240644


  Introduction Top


Percutaneous transluminal coronary angioplasty (PTCA) has now become the main stay of treatment in patients with ischemic heart disease (IHD). Till 2012, only 16 cases of coronary stent (CS) infections were reported in literature.[1]

According to Bosman et al., 57% patients present within 1st month.[2] Early diagnosis is must, and it requires high index of clinical suspicion. Coronary angiography (CAG) is considered as procedure of choice for diagnosing.[1] In our case, even though blood culture was persistently negative diagnosis was clinched using transthoracic echocardiography (TTE). In early case usually, higher dose broad spectrum antibiotics should be started and continued for at least 4 weeks. If it fails usually surgical intervention, and stent removal is required.


  Clinical Presentation Top


A 65-year-old hypertensive male presented with IWMI in August 2016. He underwent successful PTCA with stenting to distal right coronary artery (4 mm × 18 mm sirolimus drug-eluting stent) [Figure 1]. The patient was discharged but after 15 days, he started complaining of high-grade fever with chills. He was admitted at a local care center and started on intravenous ceftriaxone along with anti-malarial. Even after 7 days of admission, he continued to have high-grade fever with chills for which he was extensively investigated. Blood cultures were drawn, and basic hematological investigations were done along with complete fever profile. Except for raised white blood cell counts rest investigations were normal. Blood culture was negative. Tests for malarial, leptospira, dengue, and typhoid antigens came negative. Chest X-ray was unremarkable. Computed tomography (CT) scan of the chest showed upper lobe patchy consolidation with some pleural effusion. He was started on empirical antituberculous therapy. Despite these, he continued to have daily fever spikes and was referred to us. After admission, we performed TTE. It showed a remarkable echogenic collection in the right atrioventricular (AV) groove surrounding a hyperechoic luminal structure which was the stent [Figure 2] and [Figure 3]. A diagnosis of stent abscess was made. The patient was advised transesophageal echocardiography (TEE), but the patient refused TEE.
Figure 1: Coronary angiogram showing stenosis in distal right coronary artery and poststenting image showing TIMI III flow

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Figure 2: Apical four chamber view (two-dimensional Echo) showing collection in the right atrioventricular groove with thrombosed stent

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Figure 3: Short-axis view at aortic level clearly showing thrombosed stent in the right atrioventricular groove. AV: Atrioventricular

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Patient was started on injection meropenem 500 mg three times a day and injection amikacin 300 mg three times a day. We did CAG which showed a complete stent thrombosis just proximal to stent edge [Figure 4]. A cardiac CT was done which showed collection around the stent but no other complications [Figure 5]. Cardiovascular surgeon opinion was also sought, but it was decided to continue medical therapy as there were no obvious complications. Gradually patient responded to treatment within 7 days. Amikacin was stopped after 2 weeks while meropenem was continued for 6 weeks. Serial TTE showed a gradual resolution of collection in AV groove [Figure 6]. A positron emission tomography (PET) scan was performed which showed scarred myocardium in inferolateral region. It did not show any increased uptake at the site of suspected stent abscess maybe as it was done late in course of treatment. Hence, no further revascularization was attempted. Our case highlights the use of a simple investigation like TTE to diagnose a potentially fatal complication of PTCA in its initial stages.
Figure 4: Coronary angiography showing stent thrombosis at proximal edge of stent

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Figure 5: Cardiac computed tomography showing collection (star) in the right atrioventricular groove but no other complications

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Figure 6: No collection in the right atrioventricular groove after 4 weeks of antibiotics, showing resolution

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  Discussion Top


PTCA has become the standard of care for treating patients with acute coronary syndrome as well as in patients with stable IHD. CS infections are now being increasingly recognized. The mortality rate is high around 50%.[2] Several risk factors have been recognized which include multiple catheter exchanges through the sheath, prolonged indwelling catheters and iv lines, patient-related factors such as chronic kidney disease, elderly and females. Use of 2% glutaraldehyde for sterilization, reuse of catheters and balloons, improper implementation of aseptic procedures have also been recognized as potential risk factors.[3] In 90% of reported cases, fever is the presenting symptom. About 50% cases have chest pain which may also be caused by myocardial infarction. Delayed presentation that is more than 30 days after stent implantation has also been reported.[4] Dieter proposed a criterion for diagnosing CS infection.[5] Definitive diagnosis is by histopathological assessment of stent removed surgically or on autopsy. A possible diagnosis should be considered if any three of following criteria are met. These include CS implantation within last 4 weeks, multiple repeat procedures through the same sheath or local puncture complications, bacteremia, fever more than 101.5°C, leukocytosis and positive cardiac imaging suggesting stent abscess. Positive blood culture was seen in almost all cases, and the most common culprit was Staphylococcus aureus followed by pseudomonas aeruginosa. In our case blood, culture was persistently negative may be because of the fact patient has already received multiple antibiotics outside. In a case reported by Soman et al., they have reported cases due to atypical mycobacteria.[6] Complications include pericardial empyema, tamponade, coronary vessel perforation, ventricular rupture, and cardiac arrest, in addition to severe sepsis and multiorgan failure. In about 17 cases reported till 2012, 8 died.[1] CAG was positive in 10 of the cases, surprisingly TEE was positive only in 4 cases. Recently, PET-CT has been suggested as sensitive test.


  Conclusion Top


Fortunately, even though CS infections are rare, but they should always be kept as a differential if a patient presents within weeks of PTCA as fever. Blood cultures should be drawn immediately with imaging in the form of TTE. CAG should also be performed. Other tests such as TEE, CT, magnetic resonance imaging, and PET-CT may be considered to confirm diagnosis and to rule out complications. Proper aseptic precautions with one-time use of catheters and other hardware should be mandatory. Intravenous lines, indwelling catheters should be removed as early as possible.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors would like to thank Dr. Patil Sandeep N, Dr. Nalawade Digvijay, Dr. Borikar Nikhil, Dr. Dhanwale Shrikant, and Dr. Shah Meghav.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Elieson M, Mixon T, Carpenter J. Coronary stent infections: A case report and literature review. Tex Heart Inst J 2012;39:884-9.  Back to cited text no. 1
    
2.
Bosman WM, Borger van der Burg BL, Schuttevaer HM, Thoma S, Hedeman Joosten PP. Infections of intravascular bare metal stents: A case report and review of literature. Eur J Vasc Endovasc Surg 2014;47:87-99.  Back to cited text no. 2
    
3.
Dalal JJ, Digrajkar A, Hastak M, Mulay A, Lad V, Wani S. Coronary stent infection 8211; A grave, avoidable complication. IHJ Cardiovasc Case Rep 2017;1:77-9.  Back to cited text no. 3
    
4.
Zateyshchikov D, Fattakhova E, Demchinsky V, Baklanova T, Serebruany V. Late silent stent abscess. Cardiology 2015;132:65-7.  Back to cited text no. 4
    
5.
Dieter RS. Coronary artery stent infection. Clin Cardiol 2000;23:808-10.  Back to cited text no. 5
    
6.
Soman R, Gupta N, Suthar M, Sunavala A, Shetty A, Rodrigues C, et al. Intravascular stent-related endocarditis due to rapidly growing mycobacteria: A New problem in the developing world. J Assoc Physicians India 2015;63:18-21.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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