Ann Thorac Surg 2002;74:1697-1698
© 2002 The Society of Thoracic Surgeons
Case report
Rupture of the common carotid artery after extracorporeal membrane oxygenation
Galia Grisaru-Soen, MDa,
John G. Coles, MDb,
Brian P. Kavanagh, MBc,
Sandra R. Arnold, MDa*
a Department of Pediatrics, Division of Infectious Diseases Toronto, Canada
b Department of Surgery, Division of Cardiovascular SurgeryToronto, Canada
c Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
Accepted for publication June 20, 2002.
* Address reprint requests to Dr Arnold, Le Bonheur Children’s Medical Center, 50 N Dunlap St, Memphis, TN, 38103, Canada
e-mail: sarnold{at}utmem.edu
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Abstract
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The use of extracorporeal membrane oxygenation may be life saving but may result in serious complications. We report a rupture of the carotid artery secondary to fungal infection of the cannulation site in a pediatric patient requiring extracorporeal membrane oxygenation while awaiting a heart transplant. Prompt diagnosis and surgery resulted in a favorable outcome.
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Introduction
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Extracorporeal membrane oxygenation (ECMO) is a potentially life-saving procedure for adults and children with respiratory and cardiac failure refractory to conventional management. Known complications of ECMO include bleeding secondary to anticoagulation, pneumothorax, fluid overload, sepsis, and circuit complications. Local complications related to arterial and venous trauma from cannulation have rarely been reported. We describe a fungal arterial rupture of the carotid artery in a pediatric patient after ECMO and heart transplantation.
A 16-year-old girl who had undergone heart transplantation 4 years previously for complex congenital heart disease was admitted in acute cardiac failure. She had been maintained on a stable immunosuppressive regimen of mycophenolate mofetil and tacrolimus.
She underwent a cardiac catheterization for endomyocardial biopsy and hemodynamic assessment that was complicated by cardiac arrest. She was successfully resuscitated and transferred to the pediatric intensive care unit (PICU) and multiple inotropic medications were administered. She was empirically treated for severe rejection with methylprednisolone and antithymocyte serum. Histological assessment of the biopsy revealed distal graft vasculopathy resulting in her placement on the emergency cardiac transplant list. While awaiting heart transplant, she required support with ECMO. Cannulation for ECMO was performed in the PICU under sterile conditions via the right common carotid artery and left femoral vein.
After 48 hours on ECMO, a second heart transplant was performed and she was successfully removed from ECMO in the operating room. The carotid artery was repaired by direct suture closure of the arterial site. Her immediate posttransplant period was unremarkable. She was treated with standard immunosuppressive therapy including methylprednisolone, azathioprine, and antithymocyte serum, as well as perioperative antibacterial prophylaxis with cefazolin for 4 days. Mycostatin was given for prevention of mucosal Candida colonization. On the 7th postoperative day, bloody, purulent drainage was noted from the site of the right carotid artery cannulation, which was swabbed and sent for culture. Three hours later, during an episode of coughing, she suffered a sudden hemorrhage from the right common carotid artery. Hemostasis was maintained with direct pressure and the wound was explored in the PICU followed by transfer to the operating room.
On surgical exploration, she was found to have a rupture of the right common carotid artery at the cannulation site. Arterial ligation was judged to be the safest option and this was performed without complication. There was a long segment of macerated and necrotic appearing artery with involvement of 60% to 70% of the arterial circumference. Subsequently, culture of the initial wound swab revealed Candida albicans. She returned to the operating room 2 days later for reexploration and biopsy of the artery to confirm arterial mural Candida infection. Microscopic examination of the sections of elastic artery with periodic acid-Schiff and Gomori-methenamine silver staining revealed a collection of fungal elements, morphologically consistent with Candida species, within the media at the edge of one fragment. The collection occupied approximately two-thirds of the thickness of the media and was adjacent to a suture line. Neither the appearance of the vessel during surgery nor the pathologic specimen were consistent with ruptured aneurysm but rather direct invasion of the yeast through most of the thickness of the arterial wall without aneurysm formation. Culture of the arterial wall confirmed the presence of C. albicans. Cultures of blood, urine, and bronchoalveolar lavage fluid were negative for yeast; however, a sternal wound infection due to C. albicans was subsequently identified.
Evaluation with magnetic resonance imaging of the brain revealed an enhancing right frontal mass of 2 to 3-cm diameter and a few smaller lesions in the right cerebral hemisphere consistent with septic emboli. Neurological exam revealed diffuse weakness due to PICU myopathy which resolved slowly. Ophthalmologic examination was normal. An echocardiogram did not reveal vegetations.
The patient was treated with amphotericin B lipid complex and flucytosine intravenously for 3 months followed by oral fluconazole for 6 months. The wound healed without further complication. Follow-up magnetic resonace imaging of the brain performed 3 months after the initial episode revealed a calcified area in the right frontal lobe at the site of the previous abscess and no other lesions. The patient was eventually discharged home.
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Comment
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Mycotic arterial rupture of the carotid artery following cannulation and reconstruction for ECMO and has never been described. A case of carotid artery pseudoaneurysm as a complication of ECMO for meningococcemia has been reported [1]. This 34-month-old child presented with a pulsatile mass in the right neck at the site of the previous ECMO cannulation, secondary to disintegration of the carotid artery reconstruction. However, stains and culture for bacteria and fungi were all negative. Arterial rupture due to infection is most commonly associated with aneurysm formation. Most mycotic carotid aneurysms result from spread of local or distant infection to the blood vessel; however, mycotic carotid aneurysm due to direct trauma has occurred following percutaneous puncture of the artery for angiography or invasive hemodynamic monitoring, self-injection of intravenous drugs, and gun shot wounds [2].
Treatment of mycotic carotid aneurysm has traditionally consisted of ligation of the artery. This may be associated with substantial morbidity, especially in older patients. Revascularization with autologous material (jugular or saphenous vein) after wide debridement of the involved area is another option; however, local recurrence of infection is a possible complication.
In the present case, the carotid artery ruptured approximately 1 week after removal of the ECMO line from the right carotid artery. The usual procedure is ligation rather than repair of the artery. In this case, the vessel appeared healthy at the time of removal of the ECMO cannula and it was felt that repair by direct suturing of the arterial site as opposed to ligation was appropriate. The Candida may have been introduced into the artery at any time between insertion and removal of the cannula. Intense immunosupression with corticosteroids and antithymocyte serum for rejection prior to retransplant and prolonged PICU stay also contributed to this child’s risk for invasive fungal infection.
No aneurysm was identified in the relatively small amount of tissue submitted to pathology; however, the presence of aneurysm outside of the area of the tissue sampled cannot be excluded. Arterial rupture without aneurysm formation could be explained by rapid invasion of the yeast through the entire thickness of the arterial wall causing rupture prior to development of an aneurysm. Mechanical trauma and the potential for ischemic injury to the carotid artery at the site of cannulation as a result of disruption of the vasa vasorum may have contributed.
This complication, following ECMO, must be suspected, rapidly diagnosed, and treated in the presence of a pulsatile neck mass or bloody drainage from the cannulation site. A combination of factors likely contributed to the development of this infection in this patient including mechanical trauma to the vessel wall during cannulation and intense immunosupression consisting of antilymphocyte treatment for transplant rejection. The role for antifungal prophylaxis in heart transplant patients requires evaluation.
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References
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- Jacobs J.P., Goldman A.P., Cullen S., et al. Carotid artery pseudoaneurysm as a complication of ECMO. Ann Vas Surg 1997;11:630-633.
- Worley G.A., Hern J.D., O’Sullivan G.J., Tassone P., Hinton A.E. Mycotic aneurysm of the external carotid artery. J Laryngol Otol 1998;112:793-795.[Medline]
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Abstract
Introduction
