Management of prosthetic patch infection after CEA.

It has been reported that 0.5-1% of patients undergoing carotid endarterectomy with prosthetic patch closure of the arteriotomy will develop patch infection. One third occur within the first 2 months after surgery, while two-thirds occur after >6 months have elapsed. Wound infection and abscess formation is the commonest mode of presentation in early cases, while chronic sinus discharge and false aneurysm formation are the commonest presentations in late cases. The commonest infecting organisms are Staphylococci/Streptococci (90%) and this should be borne in mind when planning antibiotic therapy before cultures are available. Most patch infections present (semi)-electively and patch rupture is relatively rare (10%), thereby enabling the surgeon to undertake careful evaluation of the patients overall clinical and anatomical status, whilst planning the optimal treatment strategy. If necessary, the patient should be transferred to a tertiary center for treatment. This is not an operation to be undertaken by an inexperienced surgeon. Operative planning should involve checking the original operation note (did the patient tolerate carotid clamping under locoregional anesthesia and therefore might tolerate carotid ligation), is there evidence of contralateral cranial nerve lesions (a contraindication to major open surgery) and has the surgeon planned for adequate distal exposure of the internal carotid artery. Patch excision and autologous reconstruction (usually vein) is the current 'gold standard' treatment, but highly selected patients can be successfully treated by less invasive surgery (including insertion of a covered stent). Patch excision and prosthetic reconstruction should be avoided.