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INTRODUCTION:
Patch angioplasty during carotid endarterectomy (CEA) has been shown to reduce the risks of peri-operative and late stroke as well as recurrent stenosis. Two frequently used synthetic materials for patch angioplasty are polytetrafluoroethylene (PTFE) and knitted polyester (Dacron). Although complications from synthetic carotid patches are rare, infection and pseudoaneurysm formation have been reported. We report a case of a spontaneous Dacron patch expulsion without any stenosis or pseudoaneurysm formation. This is a late complication that has not been previously reported in the literature.
METHODS:
A 68 year old woman with a history of diabetes mellitus, coronary artery disease, and peripheral arterial disease underwent a left CEA with Dacron patch angioplasty for asymptomatic high grade stenosis in March of 2006. The procedure was technically unremarkable. The patient was discharged home on post operative day one with no complications. She was making a satisfactory recovery during her postoperative clinic visit at 1 month. She remained asymptomatic until January 2010. She visited her primary care physician for a ‘boil’ in the mid aspect of her incision. This was diagnosed as a stitch abscess and treated with warm compress. Over the next two months the patient had some flare ups of her incision site with minimal bloody discharge. In March of 2010, the patient removed some patch material which was extruding from the incision (Figure 1). The remainder of the patch exteriorized over the next two days.
RESULTS:
The patient visited her cardiologist who referred her for further evaluation. On follow up visit, a small sinus was present in the mid aspect of the left neck incision without any erythema or drainage. Examination of the exteriorized material confirmed expulsion of the entire Dacron patch. A selective left carotid angiogram was performed (Figure 2). The study demonstrated intact left common, internal and external carotid arteries without any evidence of stenosis or pseudoaneurysm formation. The patient was managed conservatively. The left neck sinus has subsequently healed.
CONCLUSION:
Patch angioplasty is commonly performed after CEA. Studies have demonstrated a decrease in stroke and recurrent stenosis. Synthetic material, such as Dacron or PTFE, are readily available and easy to use. The incidence of complications such as infection and pseudoaneurysm formation is extremely low. Although expulsion of a PTFE patch after CEA has been reported in two patients, based on our review of the literature, this is the first report of a Dacron patch rejection. The most likely explanation of this patient’s clinical course is a chronic patch infection with gradual sinus formation and foreign body rejection. Although no stenosis or pseudoaneurysm was visualized on this patient’s angiogram, an intact arterial wall cannot be proven without histological evaluation. Our plan is to follow this patient with serial ultrasound.