Suspected carotid stent-graft infection presenting as recurrent pseudomonas aeruginosa bacteremia after oncologic surgery: a case report.

BACKGROUND: Carotid blowout syndrome (CBS) is a catastrophic complication associated with head-and-neck surgery and other conditions involving exposure or erosion of major cervical vessels. Covered stent-graft placement can provide rapid hemostasis while preserving arterial patency. However, implantation in a contaminated field adjacent to a tracheostoma may predispose patients to devastating device-related infection, particularly in immunocompromised hosts. CASE PRESENTATION: We report the case of a 35-year-old man with stage IVB thymic carcinoma (T4N2M0) who received induction chemotherapy combined with immunotherapy followed by extended resection, including segmental tracheal resection, right thyroid lobectomy with isthmusectomy, supraclavicular island flap tracheal reconstruction, and tracheostomy. Thirteen days after discharge, he developed massive hemoptysis consistent with CBS and underwent emergency neck exploration, angiography, and placement of covered stent grafts in the right common carotid and right subclavian arteries. During the subsequent course, he developed recurrent fever, and repeated blood cultures grew Pseudomonas aeruginosa. Despite culture-directed antipseudomonal therapy and removal of indwelling central venous catheters, bacteremia recurred. Flexible fiberoptic laryngoscopy later demonstrated exposure of the vascular stent graft into the airway, strongly suggesting stent-graft infection or bacterial colonization of the exposed device. The patient subsequently developed recurrent bleeding through the tracheostoma and persistent bacteremia, followed by massive hemorrhage and progressive clinical deterioration. Because definitive surgical source control was judged to offer no acceptable risk-benefit profile after multidisciplinary reassessment, the family elected to withdraw active treatment. CONCLUSIONS: This case suggests that covered stent placement in a contaminated head-and-neck field should be undertaken with great caution, as subsequent bacterial colonization or stent-graft infection may occur and may further lead to recurrent or even catastrophic hemorrhage. When stent implantation is unavoidable, early multidisciplinary evaluation is essential, and every effort should be made to prevent wound infection, bacterial colonization of the device, and related bleeding complications.