# Systematic Review and Meta-analysis of Occurrence Rate, Treatments, and Outcomes of Vascular Graft and Stent Infections in the Supra-aortic Trunks

Paolo Perini, Marjan Wouthuyzen-Bakker, Oliver Lyons, Ivika Heinola, Alexandra Catasta, Anne Lejay

► To cite this version:

Paolo Perini, Marjan Wouthuyzen-Bakker, Oliver Lyons, Ivika Heinola, Alexandra Catasta, et al. Systematic Review and Meta-analysis of Occurrence Rate, Treatments, and Outcomes of Vascular Graft and Stent Infections in the Supra-aortic Trunks. European Journal of Vascular and Endovascular Surgery, 2025, 70 (3), pp.377-387. 10.1016/j.ejvs.2025.05.006. hal-05333858

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## SYSTEMATIC REVIEW

# Editor's Choice – Systematic Review and Meta-analysis of Occurrence Rate, Treatments, and Outcomes of Vascular Graft and Stent Infections in the Supra-aortic Trunks

Paolo Perini<sup>a,b,*</sup>, Marjan Wouthuyzen-Bakker<sup>c</sup>, Oliver T. Lyons<sup>d</sup>, Ivika Heinola<sup>e</sup>, Alexandra Catasta<sup>a,b</sup>, Anne Lejay<sup>f</sup>

### WHAT THIS PAPER ADDS

This paper highlights that vascular graft and stent infections in the supra-aortic trunks are rare but challenging. While the gold standard treatment for carotid endarterectomy (CEA) patch infection is removal of the infected prosthetic material followed by autologous reconstruction, alternative approaches such as infected tissue debridement, stent graft relining, and negative pressure wound therapy are viable options. Cranial nerve injuries are more common after treatment of CEA patch infection than after primary CEA and are often permanent.

**Objective:** This study aimed to systematically review and synthesise the available evidence on the management of vascular graft and stent infections in the supra-aortic trunks (SATs).

**Data Sources:** MEDLINE, Scopus, Cochrane databases, and citation searching.

**Review Methods:** All study designs (case reports and series, cohort studies, and trials) addressing treatments for post-operative infections of prosthetic vascular grafts and stents in the SAT were included. GRADE methodology was used to assess the certainty of evidence.

**Results:** Seventy one studies were included in this systematic review. Fifty four were case reports and case series (215 patients) describing SAT infections following surgery. Among these, 11 studies with 149 patients who initially underwent carotid endarterectomy (CEA) with patch closure were included in the meta-analysis. The estimated infection rate after CEA with patch closure was 0.7% (95% confidence interval [CI] 0.4 – 0.9%). Surgical treatment was mostly based on complete removal of the infected material and *in situ* arterial reconstruction (82.2%, 95% CI 71.4 – 92.9%). Post-operative complications occurred in 25.9% (95% CI 16.0 – 35.9%). Cranial nerve injury occurred in 12.5% (95% CI 5.7 – 19.4%), with 28.4% (95% CI 5.2 – 57.4%) of these being permanent. Re-infections during a mean follow up of 37.7 months occurred in 3.4% of patients. Seventeen studies were case reports documenting SAT infections in 21 patients following endovascular treatment. Stent explantation was performed in 18 of 21 cases. A reconstruction to restore SAT flow was performed in 11 of 18 cases. GRADE analysis determined the certainty of evidence for all outcomes to be very low.

**Conclusion:** Vascular graft and stent infections in the SATs are uncommon. The preferred treatment was removal of the infected graft and autologous reconstruction. Alternatives included drainage, stent relining, and antibiotics. Cranial nerve injuries were common, with one third resulting in permanent damage.

**Keywords:** Brachiocephalic trunk, Carotid arteries, Infection, Stent, Subclavian artery, Surgical procedures

Article history: Received 29 September 2024, Accepted 3 May 2025, Available online 10 May 2025

© 2025 The Author(s). Published by Elsevier B.V. on behalf of European Society for Vascular Surgery. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

<footnote><sup>a</sup>Vascular Surgery, Cardio-Thoracic and Vascular Department, University Hospital of Parma, Parma, Italy</footnote>

<footnote><sup>b</sup>Department of Medicine and Surgery, University of Parma, Parma, Italy</footnote>

<footnote><sup>c</sup>Department of Medical Microbiology and Infection Prevention, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands</footnote>

<footnote><sup>d</sup>Vascular Surgery, University of Otago Christchurch, Christchurch, New Zealand</footnote>

<footnote><sup>e</sup>Department of Vascular Surgery, Helsinki University and Helsinki University Hospital, Helsinki, Finland</footnote>

<footnote><sup>f</sup>Department of Vascular Surgery, Kidney Transplantation and Innovation, University Hospital of Strasbourg, Strasbourg, France</footnote>

<footnote>* Corresponding author. Vascular Surgery, Cardio-Thoracic and Vascular Department, University Hospital of Parma, Via Gramsci 14, Parma 43126, Italy.
E-mail address: paolo.perini@unipr.it (Paolo Perini).
1078-5884/© 2025 The Author(s). Published by Elsevier B.V. on behalf of European Society for Vascular Surgery. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
https://doi.org/10.1016/j.ejvs.2025.05.006</footnote>
# INTRODUCTION

Infections following open or endovascular procedures in the supra-aortic trunks (SATs), although rare, present significant diagnostic and therapeutic challenges for surgeons.¹,² Clinical outcomes of prosthetic infections are often worse than the natural progression of the underlying disease that necessitated the initial vascular reconstruction. Furthermore, there is no consensus on the optimal management of these infections.¹ If left untreated, they can lead to severe local and systemic complications such as sepsis, pseudoaneurysm formation, and ultimately arterial rupture. This progression might result in varying degrees of stroke, and in many cases may culminate in death.³,⁴

On the other hand, surgical intervention, while necessary, carries its own set of serious complications, including cranial nerve injury, peri-operative stroke, major bleeding, re-infection, and a significant risk of death.⁵⁻⁷ As an alternative to open surgery, some authors have proposed conservative management (patch or stent preservation combined with antimicrobial therapy and possibly abscess drainage) or endovascular management with covered stent implantation.⁸,⁹ The balance between the risks associated with natural disease progression and the potential complications of surgical intervention, and the lack of good data to guide management, has created a challenging clinical scenario. This study aimed to systematically review and synthesise the available evidence on the management of vascular graft and endograft infections in the SATs, updating and expanding upon an earlier comprehensive review.¹⁰ By providing a critical appraisal of the literature, the study sought to inform clinical decision making and support the development of evidence based practices for these challenging cases.

# METHODS

## Data sources, search strategy, and selection criteria

The study adhered to the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Supplementary Table S1).¹¹ This review was not registered prospectively. The research was built on a PICO (Patient; Intervention; Comparison; Outcome) question: In patients with vascular graft and stent infection in the supra-aortic trunks, is complete material removal and autologous reconstruction, compared with graft preservation strategies, effective in terms of cure of infection? A comprehensive search for scientific studies describing the treatment of post-operative infection of prosthetic vascular grafts and stents in the SATs was conducted across multiple databases, including MEDLINE, Scopus, and the Cochrane Library. Additionally, the reference lists of relevant articles were reviewed to identify further pertinent studies. The final search was completed on 11 June 2024. The full strategy is available in Supplementary Table S2. The database search was performed by two authors (P.P. and A.C.), and any disagreements were resolved through consensus between them.

Studies were included if they reported on the outcomes of interventions for post-operative infections of prosthetic vascular grafts (including patches) or stents in the SAT.

The diagnosis of infection was as reported by each study's authors, relying on their respective clinical and radiological criteria.¹⁰ The SAT was defined as involving the brachiocephalic trunk, carotid arteries, or subclavian arteries. Case reports and case series, cohort studies, and clinical trials were included. Non-English language articles were considered if an English abstract was available, with data extracted from the abstract alone.

The inclusion criteria were: (i) patients developing a post-operative infection following prosthetic vascular graft implantation (bypass graft or vascular patch) or stent (covered or uncovered) deployment; (ii) documentation of endovascular, surgical, or conservative treatment of the infection; and (iii) availability of extractable outcome data, such as intra-operative and or early results. The exclusion criteria were: (i) primary arterial infections; (ii) experimental studies; (iii) heterogeneous series with patients undergoing both watchful waiting and open and or endovascular repair without clear extractable data for each treatment type; (iv) axillofemoral bypasses; (v) infection of venous materials; (vi) studies on cardiac or non-vascular materials or stents; and (vii) infections involving venous segments or vascular accesses for haemodialysis. For studies potentially originating from a single database, only the most recent study was selected for data extraction.

## Data extraction, outcome measures, and evaluation of study quality

Data extraction and quality assessment were independently conducted by two authors (P.P. and A.C.), and any disagreements were resolved by the senior author (A.L.). The extracted data included: study design (type of study, publication type, retrospective or prospective analysis, type of treatment, presence of treatment comparison); cohort characteristics (number of patients, type of initial treatment and location of implanted material, study timeframe, follow up duration, urgency of treatment); baseline demographics (age, sex); time to diagnosis; pre-operative imaging and analysis including cultures; and related early (< 30 days) and follow up outcomes and complications. Data that could not be deduced were marked as not reported or not extractable. The quality of the studies was evaluated using the Joanna Briggs Institute (JBI) tool.¹² Studies with six or more Yes responses were included in the meta-analysis. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was used to assess the certainty of evidence.¹³

Primary outcomes were identified prior to data extraction and included mode of treatment and early outcomes (death, re-intervention, re-infection, stroke, bleeding, cranial nerve injury). Secondary outcomes were long term data (re-infection, re-intervention, death) and post-operative antibiotic treatment.

## Statistical analysis

Data were recorded in a Microsoft Excel spreadsheet (Microsoft Corp., Redmond, WA, USA). A meta-analysis of all articles including five or more patients was performed. Case reports
and small case series (fewer than five patients) were used for the qualitative synthesis. The meta-analysis was conducted using Prometa 3.0 software (based on Prometa 2.1; Internovi, Cesena, Italy) and OpenMeta [Analyst].¹⁴ Outcomes were synthesised and reported if provided in two or more studies. Continuous data were presented as the weighted mean with their 95% confidence interval (CI). When the mean ± standard deviation was not provided, these values were estimated from the median, range, and sample size, where possible.¹⁵ Propor- tion meta-analysis was carried out using the Freeman–Tukey transformed proportion (double arcsine transformation) with a random effects model (DerSimonian–Laird method) to account for potential interstudy heterogeneity. Pooled results were reported as percentages with 95% CI. Heterogeneity was assessed using an I² calculation. The presence of publication bias was explored by performing Egger's test and by visual-isation of funnel plots. A two sided *p* value of < .050 was considered statistically significant.

## RESULTS

The initial search yielded 1 303 unique publications, of which 65 underwent full text review. In parallel, 31 studies were identified through citation searching. Ultimately, 71 studies met the criteria for inclusion in the systematic review (Fig. 1).³⁻⁷,¹⁶⁻⁸¹ Overall, data on 236 patients were available.

Fifty four studies reported prosthetic material infection following open surgery (patches or prosthetic conduits) in 215 patients.³⁻⁶,¹⁶⁻¹⁹,21,²²,²⁴,²⁷⁻³⁴,³⁸⁻⁴¹,⁴³,⁴⁶⁻⁵⁸,⁶¹⁻⁶⁹,⁷¹⁻⁷⁴,⁷⁷,⁷⁹⁻⁸¹

Among these, 11 studies reported series of at least five patients (149 patients in total) and were therefore included in the

meta-analysis.⁵,¹⁶,²²,³²,⁴⁷,⁴⁸,⁵³,⁵⁵,⁵⁸,⁶⁴,⁶⁶ Due to lack of comparative data in the included studies, a one group variable synthesis was carried out.

Seventeen studies addressed stent infection and included 21 patients in total.⁷,²⁰,²³,²⁵,²⁶,³⁵⁻³⁷,⁴²,⁴⁴,⁴⁵,⁵⁹,⁶⁰,⁷⁰,⁷⁵,⁷⁶,⁷⁸ All these studies were case reports including one or two patients; thus, a meta-analysis was not feasible.

## Supra-aortic trunk infections after open treatment

All of the studies reporting on SAT infection after open treatment included in the meta-analysis entailed patch infection after carotid endarterectomy (CEA), in 149 patients (Table 1).⁵,¹⁶,²²,³²,⁴⁷,⁴⁸,⁵³,⁵⁵,⁵⁸,⁶⁴,⁶⁶ The median number of Yes responses in the JBI appraisal was 7.5 (range 6 – 9), indicating moderate to high methodological quality across the studies (Supplementary Table S3). Given the study design, risk of bias, and heterogeneity, GRADE analysis determined the overall quality of evidence for all outcomes to be very low (Table 2). The pooled estimate of the infection rate after CEA with patch closure was 0.7% (95% CI 0.4 – 0.9%; I² = 53.0%; *p* = .037) (Supplementary Figure S1), based on eight studies reporting on occurrence rate and a total of 11 782 patients.⁵,¹⁶,²²,³²,⁴⁸,⁵⁵,⁵⁸,⁶⁴,⁶⁶

The vast majority of infected materials were polyester patches, with a pooled estimate of 80.8% (95% CI 61.8 – 99.8%; I² = 96.4%; *p* < .001), followed by polytetrafluoroethylene (PTFE), with a pooled estimate of 12.9% (95% CI 0.7 – 25.1%; I² = 91.2%; *p* < .001), based on 11 studies and 149 patients; these should be interpreted as the proportion of use rather than infection rates for each material type. Information on sex was extractable in seven studies (85 patients) and the pooled

<figure><img src="image_2.png" /></figure>
<table><caption>**Table 1.** Characteristics of studies (n = 11) included in the meta-analysis reporting on vascular patch infections after carotid endarterectomy.</caption><thead><tr><th rowspan="2">Author, year</th><th rowspan="2">Patients - n</th><th rowspan="2">Mean age - y</th><th rowspan="2">Mean time to presentation - mo</th><th rowspan="2">Mean follow up - mo</th><th colspan="5">Follow up outcomes - n (%)</th></tr><tr><th>Re-infection</th><th>Stroke/TIA</th><th>Re-stenosis</th><th>Re-intervention</th><th>Death</th></tr></thead><tbody><tr><td>Shehab, 2024<sup>53</sup></td><td>9</td><td>72.8</td><td>30.4</td><td>87.6</td><td>0</td><td>0</td><td>3 (33.3)</td><td>2 (22.2)</td><td>3 (33.3)</td></tr><tr><td>Fatima, 2019<sup>58</sup></td><td>29</td><td>70</td><td>24.3</td><td>17</td><td>0</td><td>1 (3.4)</td><td>1 (3.4)</td><td>0 (0)</td><td>4 (13.8)</td></tr><tr><td>Alawy, 2017<sup>48</sup></td><td>8</td><td>69.8</td><td>49.2</td><td>24</td><td>0</td><td>1 (12.5)</td><td>0 (0)</td><td>1 (12.5)</td><td>2 (25.0)</td></tr><tr><td>Mann, 2012<sup>55</sup></td><td>22</td><td>NR</td><td>24.7</td><td>71.8</td><td>0</td><td>1 (4.5)</td><td>1 (4.5)</td><td>0 (0)</td><td>8 (36.4)</td></tr><tr><td>Stone, 2011<sup>16</sup></td><td>25</td><td>67</td><td>6.0</td><td>27</td><td>NE</td><td>NE</td><td>NE</td><td>NE</td><td>NE</td></tr><tr><td>Naughton, 2010<sup>22</sup></td><td>12</td><td>76.3</td><td>22.4</td><td>31.1</td><td>1 (8.3)</td><td>0 (0)</td><td>0 (0)</td><td>0 (0)</td><td>4 (33.3)</td></tr><tr><td>Asciutto, 2007<sup>5</sup></td><td>6</td><td>69.3</td><td>4.5</td><td>55.3</td><td>2 (33.3)</td><td>1 (16.7)</td><td>0 (0)</td><td>0 (0)</td><td>2 (33.3)</td></tr><tr><td>Rockman, 2003<sup>64</sup></td><td>10</td><td>73.1</td><td>8.6</td><td>21.1</td><td>0 (0)</td><td>0 (0)</td><td>0 (0)</td><td>0 (0)</td><td>0 (0)</td></tr><tr><td>Naylor, 2002<sup>66</sup></td><td>8</td><td>NR</td><td>12.7</td><td>43.9</td><td>0 (0)</td><td>1 (12.5)</td><td>0 (0)</td><td>0 (0)</td><td>0 (0)</td></tr><tr><td>Rizzo, 2000<sup>32</sup></td><td>8</td><td>68</td><td>9.1</td><td>15.6</td><td>0 (0)</td><td>1 (12.5)</td><td>0 (0)</td><td>0 (0)</td><td>1 (12.5)</td></tr><tr><td>El-Sabrout, 2000<sup>47</sup></td><td>12</td><td>67.0</td><td>24.5</td><td>61.2</td><td>3 (25.0)</td><td>0 (0)</td><td>0 (0)</td><td>2 (16.7)</td><td>2 (16.7)</td></tr><tr><td>Pooled estimate (95% CI)<sup>*</sup></td><td>149</td><td>70.6 y (68.2-73.0)</td><td>17.9 mo (10.9-24.9)</td><td>37.7 mo (26.7-48.6)</td><td>3.4 (0.4-6.5)</td><td>4.9 (1.2-8.6)</td><td>4.7 (1.1-8.3)</td><td>3.4 (0.3-6.4)</td><td>17.1 (9.3-24.8)</td></tr></tbody></table>

TIA = transient ischaemic attack; NR = not reported; NE = not extractable; CI = confidence interval.

* Pooled estimates are given as percentages unless otherwise stated.

estimate of males was 61.7% (95% CI 47.6 – 75.8%; $I^2 = 48.2$; $p = .072$).<sup>5,22,32,47,48,58,64</sup> The pooled estimate of mean age at presentation was 70.6 years (95% CI 68.2 – 73.0 years; $I^2 = 54.6$%; $p = .024$), based on nine studies and 119 patients.<sup>5,16,22,32,47,48,53,58,64</sup>

The pooled estimate of mean time elapsed from initial surgical procedure to patient presentation with prosthetic infection was 17.9 months (95% CI 10.9 – 24.9 months; $I^2 = 74.2$%; $p < .001$) (Supplementary Figure S2), based on 11 studies and 149 patients. Symptoms or signs of carotid patch infections were reported in all cases, and the following pooled estimates were based on all 149 patients in the 11 included studies. The most commonly reported symptoms or signs were draining sinus (34.6%, 95% CI 19.5 – 49.8%; $I^2 = 86.6$%; $p < .001$), abscess (28.2%, 95% CI 16.2 – 40.1%; $I^2 = 70.6$%; $p < .001$), neck mass (13.5%, 95% CI 8.0 – 19%; $I^2 = 7.2$%; $p = .38$), false aneurysm or patch dehiscence (12.7%, 95% CI 7.2 – 18.1%; $I^2 = 11.4$%; $p = .34$), and bleeding (9.6%, 95% CI 4.1 – 15.1%; $I^2 = 33.5$%; $p = .13$). Other less frequently reported signs or symptoms were pain, fever, and neurological symptoms (stroke or transient ischaemic attack).

The most adopted pre-operative imaging modalities were duplex ultrasound (DUS), with a pooled estimate of 67.2% (95% CI 44.7 – 89.6%; $I^2 = 93.0$%; $p < .001$), and computed tomography (CT) angiography (46.4%, 95% CI 12.9 – 79.9%; $I^2 = 96.7$%; $p < .001$), based on the 11 studies and 149 patients

(Table 3). Magnetic resonance imaging (MRI) and digital subtraction angiography were used less commonly. Positron emission tomography (PET) was never used in the included studies. The use of leukocyte scintigraphy was reported in one study (seven of eight were negative).<sup>48</sup>

Microbiological cultures were performed for all patients in the included studies. Cultures were obtained intra-operatively in 97.1% of cases (95% CI 94.2 – 99.9%; $I^2 = 0$%; $p = .92$), based on eight studies and 124 patients.<sup>16,22,32,47,48,55,58,66</sup> *Staphylococcus* spp. were the most frequently isolated microorganisms, accounting for a pooled estimate of 48.7% (95% CI 37.5 – 59.9%; $I^2 = 40.4$%; $p = .088$). *Staphylococcus aureus* was isolated in 23.4% (95% CI 13.3 – 33.4%; $I^2 = 47.5$%; $p = .055$) of cultures. *Staphylococcus epidermidis* was more frequently associated with infections occurring more than six months after initial surgery and was found in 13.5% (95% CI 4.0 – 23%; $I^2 = 37.1$%; $p = .16$) of cases. *Streptococcus* spp. were present in 8.2% of included cases (95% CI 3.5 – 12.9%; $I^2 = 0$%; $p = .64$). Cultures were sterile in a pooled estimate of 25.4% (95% CI 12.0 – 38.7%; $I^2 = 83.3$%; $p < .001$).

Regarding surgical management (Fig. 2), debridement of the infected surrounding tissues was performed in almost all cases, with a pooled estimate of 96.9% (95% CI 94.3 – 99.6%; $I^2 = 0$%; $p = 1.0$), based on all 149 patients in the 11 included studies. Complete removal of the infected material was performed in 87.4% of cases (95% CI 78.4 – 96.4%; $I^2 = 80.7$%; $p < .001$).
<table><caption>**Table 2.** Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessment for primary and secondary outcomes regarding vascular patch infections after carotid endarterectomy.</caption><thead><tr><th>Outcome</th><th>Effect estimate (95% CI)*</th><th>I<sup>2</sup> - %</th><th>Participants - n</th><th>Studies - n</th><th>Certainty of evidence (GRADE)</th></tr></thead><tbody><tr><td>Debridement of infected tissues</td><td>96.9 (94.3-99.6)</td><td>0</td><td>149</td><td>11</td><td>⊕ O O O<br>Very low</td></tr><tr><td>Complete material removal</td><td>87.4 (78.4-96.4)</td><td>80.7</td><td>149</td><td>11</td><td>⊕ O O O<br>Very low</td></tr><tr><td>Reconstruction after material removal</td><td>82.2 (71.4-92.9)</td><td>84.5</td><td>149</td><td>11</td><td>⊕ O O O<br>Very low</td></tr><tr><td>Venous grafts for reconstruction</td><td>59.3 (36.4-82.3)</td><td>96.3</td><td>149</td><td>11</td><td>⊕ O O O<br>Very low</td></tr><tr><td>Use of muscle flaps</td><td>5.2 (1.3-9.1)</td><td>23.9</td><td>149</td><td>11</td><td>⊕ O O O<br>Very low</td></tr><tr><td>Post-operative death</td><td>3.4 (0.6-6.2)</td><td>0</td><td>149</td><td>11</td><td>⊕ O O O<br>Very low</td></tr><tr><td>Post-operative stroke</td><td>5.2 (1.7-8.7)</td><td>0</td><td>149</td><td>11</td><td>⊕ O O O<br>Very low</td></tr><tr><td>Cranial nerve injury</td><td>12.5 (5.7-19.4)</td><td>50.2</td><td>149</td><td>11</td><td>⊕ O O O<br>Very low</td></tr><tr><td>Cranial nerve injury, permanent</td><td>28.4 (5.2-57.4)</td><td>28.39</td><td>25</td><td>7</td><td>⊕ O O O<br>Very low</td></tr><tr><td>Re-intervention for bleeding</td><td>4.5 (1.3-7.7)</td><td>0</td><td>149</td><td>11</td><td>⊕ O O O<br>Very low</td></tr><tr><td>Follow up duration</td><td>37.7 mo (26.7-48.6)</td><td>89.8</td><td>149</td><td>11</td><td>⊕ O O O<br>Very low</td></tr><tr><td>Re-infection during follow up</td><td>3.4 (0.4-6.5)</td><td>0</td><td>124</td><td>10</td><td>⊕ O O O<br>Very low</td></tr><tr><td>Death during follow up</td><td>17.1 (9.3-24.8)</td><td>32.1</td><td>124</td><td>10</td><td>⊕ O O O<br>Very low</td></tr><tr><td>Re-intervention during follow up</td><td>3.4 (0.3-6.4)</td><td>0</td><td>124</td><td>10</td><td>⊕ O O O<br>Very low</td></tr><tr><td>Mean time from initial procedure to patient presentation</td><td>17.9 mo (10.9-24.9)</td><td>74.2</td><td>11</td><td>149</td><td>⊕ O O O<br>Very low</td></tr><tr><td>Occurrence rate after endarterectomy with patch closure</td><td>0.7 (0.4-0.9)</td><td>53</td><td>11782</td><td>8</td><td>⊕ O O O<br>Very low</td></tr></tbody></table>

CI = confidence interval.

* Effect estimates are given as percentages unless otherwise stated.

Twenty four of 149 patients who did not undergo complete removal of the infected material underwent conservative treatment (one patient deemed at high surgical risk treated with medical therapy alone and one patient treated with covered stent) or drainage associated with wound irrigation and antibiotic therapy (22 patients). A reconstruction after material removal was performed in 82.2% of the 149 patients (95% CI

71.4 – 92.9%; I² = 84.5%; *p* < .001). Venous graft (great saphenous vein, jugular vein, or superficial femoral vein) was the most commonly used material for reconstruction (59.3%, 95% CI 36.4 – 82.3%; I² = 96.3%; *p* < .001). Use of artery grafts was reported in six cases, cryopreserved allograft in three, prosthetic grafts in five, and covered stents in ten.²²,⁴⁷,⁵³,⁵⁵ Bypass grafts (43.0%, 95% CI 18.7 – 67.2%; I² = 94.8%; *p* < .001) were

<table><caption>**Table 3.** Description of diagnostic imaging modalities used for vascular patch infections after carotid endarterectomy.*</caption><thead><tr><th>Diagnostic modality</th><th>Frequency of use (95% CI) - %</th><th>I<sup>2</sup> - %</th><th>p value</th></tr></thead><tbody><tr><td>Duplex ultrasound</td><td>67.2 (44.7-89.6)</td><td>93.0</td><td>&lt;.001</td></tr><tr><td>CT angiography</td><td>46.4 (12.9-79.9)</td><td>96.7</td><td>&lt;.001</td></tr><tr><td>MRI</td><td>12.4 (2.9-21.8)</td><td>48.0</td><td>.090</td></tr><tr><td>Digital subtraction angiography</td><td>8.5 (2.0-14.9)</td><td>0</td><td>.43</td></tr><tr><td>Leukocyte scintigraphy</td><td>11.7 (1.4-22.0)</td><td>92.9</td><td>&lt;.001</td></tr><tr><td>18F-FDG PET-CT</td><td>Not reported in included studies</td><td>—</td><td>—</td></tr></tbody></table>

CI = confidence interval; CT = computed tomography; MRI = magnetic resonance imaging; 18F-FDG PET-CT = ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography.

* Data based on the 11 studies included in the meta-analysis considering a total of 149 patients.
<figure><img src="image_3.png" /></figure>

preferred over patch substitutions (26.2%, 95% CI 13.5 – 38.8%; $I^2$ = 80.5%; *p* < .001). Primary closure of the carotid artery was reported in two cases.²²,⁴⁷ Use of muscle flaps was reported in a pooled estimate of 5.2% of the 149 patients (95% CI 1.3 – 9.1%; $I^2$ = 23.9%; *p* = .22).¹⁶,²²,⁴⁸

The pooled estimate of any post-operative complication (death, cardiac events, respiratory failure, re-intervention, re-infection, stroke, bleeding, cranial nerve injury) was 25.9% (95% CI 16.0 – 35.9%; $I^2$ = 55.1%; *p* = .014), based on all 149 patients in the 11 included studies. Post-operative death occurred in 3.4% of patients (95% CI 0.6 – 6.2%; $I^2$ = 0%; *p* = 1.0). The pooled estimate of post-operative stroke was 5.2% (95% CI 1.7 – 8.7%; $I^2$ = 0%; *p* = .99). Cranial nerve injury was reported in a pooled estimate of 12.5% (95% CI 5.7 – 19.4%; $I^2$ = 50.2%; *p* = .029). Of these injuries, 28.4% (95% CI 5.2 – 57.4%; $I^2$ = 28.4%; *p* = .21) were permanent.¹⁶,²²,⁵⁵ Re-intervention for post-operative bleeding was required in a pooled estimate of 4.5% (95% CI 1.3 – 7.7%; $I^2$ = 0%; *p* = .90).

Data regarding antibiotic management were extremely heterogeneous and frequently not reported; statistical analysis was therefore not feasible.

The pooled estimate of mean length of follow up was 37.7 months (95% CI 26.7 – 48.6 months; $I^2$ = 89.8%; *p* < .001), based on all 149 patients in the 11 included studies. Data on complications during follow up were extractable in ten studies (124 patients).⁵,²²,³²,⁴⁷,⁴⁸,⁵³,⁵⁵,⁵⁸,⁶⁴,⁶⁶ The pooled estimate of re-infection during follow up was 3.4% (95% CI 0.4 – 6.5%; $I^2$ = 0%; *p* = .66). Stroke was estimated in 4.9% (95% CI 1.2 – 8.6%; $I^2$ = 0%; *p* = .99). The pooled estimate of death during follow up was 17.1% (95% CI 9.3 – 24.8%; $I^2$ = 32.1%; *p* = .15), mostly due to unrelated causes. Re-stenosis or carotid occlusions occurred in 4.7% of cases (95% CI 1.1 – 8.3%; $I^2$ = 0%; *p* = .94). Re-interventions were necessary in a pooled estimate of 3.4% of patients (95% CI 0.3 – 6.4%; $I^2$ = 0%;

*p* = .83) and were due to re-stenosis, thrombosis, or false aneurysm development; they were all treated by endovascular means.

Egger's test was statistically non-significant for occurrence rate (*p* = .70), mean age at presentation (*p* = .43), and post-operative complications (*p* = .060). Egger's test was statistically

<figure><img src="image_4.png" /></figure>
significant for mean time elapsed from surgical procedure to patient presentation (p = .001) and follow up length (p = .010). Funnel plots are given in Supplementary Figure S3.

**Supplementary Table S4** summarises all the case reports and small case series (43 studies) that were not included in the meta-analysis above, including a total of 66 patients.⁵,⁴,⁶,¹⁷⁻¹⁹,²¹,²⁴,²⁷⁻³¹,³³,³⁴,³⁸⁻⁴¹,⁴³,⁴⁶,⁴⁹⁻⁵²,⁵⁴,⁵⁶,⁵⁷,⁶⁵,⁶⁷⁻⁶⁹,⁷¹⁻⁷⁴,⁷⁷,⁷⁹⁻⁸¹ Most of them were carotid patch infections, while 12 were bypasses involving the SATs.¹⁷,²⁷⁻²⁹,⁵³,⁵⁴,⁷⁷,⁸¹

## Supra-aortic trunk infections after endovascular treatment

Regarding the 17 studies addressing SAT stent infections, 14 were single case reports⁷,²⁰,²³,²⁶,³⁷,⁴²,⁴⁴,⁴⁵,⁵⁹,⁶⁰,⁷⁰,⁷⁵,⁷⁶,⁷⁸ and three studies reported on two or three cases,²⁵,³⁵,³⁶ including a total of 21 patients. Sixteen cases were carotid stent infections⁷,²⁰,²³,²⁵,²⁶,³⁵,³⁶,⁴⁴,⁵⁹,⁷⁰,⁷⁵,⁷⁸ and five were subclavian stent infections.³⁷,⁴²,⁴⁵,⁶⁰,⁷⁶ The SAT stent was a covered stent in four of 21 patients.⁷,³⁵,⁷⁸ Time to presentation from initial stent implantation ranged from nine days to 30 months.⁷,⁶⁰

Fever was a frequent symptom (ten cases). Stent infection was often associated with symptoms related to septic embolisation, such as intracerebral abscess formation or distal embolism (five cases).⁷,²⁰,³⁷,⁴²,⁷⁶ False aneurysm development was another common presentation, reported in seven cases.

Regarding treatment, stent explantation was performed in 18 of 21 cases (Fig. 3). In one case, partial removal of a Wallstent (Boston Scientific, Natick, MA, USA) was possible.⁵⁹ In one case the endovascular material was not initially explanted and the patient underwent endovascular embolisation of the carotid axis; stent explantation was then required after 24 weeks.⁷ Post-operative complications were reported in five cases, including stroke, heart failure, bleeding, nerve injury, re-infection, and death.²⁵,³⁵,³⁷,⁴²,⁴⁴

Post-operative follow up ranged from one month to three years.⁷,⁷⁵ Outcomes were reported for 15 of 21 patients.⁷,²⁵,³⁵⁻³⁷,⁴²,⁴⁴,⁴⁵,⁵⁹,⁶⁰,⁷⁵,⁷⁶,⁷⁸ Five of 15 patients were alive at reported follow up, and eight of 15 were reported as free from re-infection. In two cases the cause of death was probably related to the SAT stent infection: one case of persistent sepsis and one case of stroke.³⁵,⁴² Complete data are reported in Supplementary Table S5.

## DISCUSSION

Infections following implantation of prosthetic vascular graft or endovascular material in the SAT were rare; it is believed that only 232 cases have been described in the literature. The infection rate was estimable only after CEA with patch angioplasty: in the current meta-analysis, the estimated infection rate after CEA with patch closure was 0.7%, with moderate heterogeneity among different studies (I² = 53.0%). This rate appears to be lower than for lower limb prosthetic bypass infections (up to 2.5% in femorofemoral bypasses and up to 2.8% in femoropopliteal bypasses).⁸²,⁸³ The rate of post-operative infections was probably lower after endovascular SAT treatment, and probably even lower than the 0.3% reported after

endovascular repair of the abdominal aorta, owing to the frequent use of uncovered stents in the SATs and the small amount of implanted material.⁸⁴ Under reporting or lack of recognition should be considered as an alternative explanation.⁸⁵ Prophylactic measures are of paramount importance in minimising the risk of these infections.⁵,³⁷,⁴⁸,⁵⁵,⁵⁹,⁶⁶ In addition to ensuring skin disinfection and adhering to theatre antisepsis protocols, patients undergoing arterial reconstructions should receive systemic antibacterial prophylaxis, as there is clear evidence of its benefits.⁸⁶ Pericardial bovine patches could be considered for carotid angioplasty after CEA; Alawy et al. reported a 0% infection rate with the use of biological patches.⁴⁸

Infection of vascular grafts or stents in the SATs occurred any time from the first few days after implantation to more than ten years later, underscoring the complexity and unpredictability of these complications.

No reports of asymptomatic SAT vascular material infection were found, probably because patients with asymptomatic presentations were less likely to re-present or undergo routine follow up, particularly without specific radiological imaging that could detect subclinical seeding infections. Signs or symptoms were different following surgery or endovascular repair. In fact, after CEA with patch angioplasty, signs of infection at the level of the incision such as draining sinus, abscess, neck mass, or bleeding were frequent, while fever was rarely reported and more prevalent for early occurring cases. In contrast, fever and systemic sepsis signs were frequently reported after carotid artery stent infection.

The imaging modality usually adopted for CEA follow up was DUS. Besides providing information on possible re-stenosis, Lazaris et al. reported that patch corrugation observed on DUS might be an early warning sign of infection, potentially preceding clinical symptoms by up to a year.⁶¹ However, before proceeding with surgical treatment, a second level diagnostic investigation, such as CT or MRI, was generally advised, as it is crucial for accurate treatment planning and to ensure that the precise location of the infection is identified. PET-CT was not reported as a diagnostic method in the current meta-analysis, probably because the authors did not consider it necessary for their specific cases. However, if uncertainty arises, an ¹⁸F-fluorodeoxyglucose (18F-FDG) PET-CT scan could be recommended, since it has been demonstrated to be a useful diagnostic method in detecting active vascular graft infection with high diagnostic accuracy at other sites.⁸⁷ Leukocyte scintigraphy was rarely reported, and often provided negative results; thus, its use may not be appropriate, especially for late occurring infections.⁴⁸

Microbiological cultures were generally obtained from intra-operative samples, accounting for 97.1% in the current meta-analysis, with no heterogeneity among the included studies. Blood cultures were reported infrequently and were often negative. This may be because systemic sepsis signs were uncommon, particularly following open surgery. *Staphylococcus* spp. were the most frequently isolated microorganisms following both open surgery (48.7%, with moderate heterogeneity) and endovascular treatments (11 of 21 cases).
Notably, negative cultures were observed in a significant proportion of patients (25.4%, 95% CI 12.0 – 38.7%). These results were probably influenced by the fact that patients were started on broad spectrum antibiotic treatment before samples were obtained. Cultures could be combined with 16S rRNA gene polymerase chain reaction from peri-prosthetic tissue and or explanted vascular grafts to increase the diagnostic accuracy in vascular graft infection, especially in patients receiving antimicrobial therapy prior to revision surgery.⁸⁸,⁸⁹ To optimise microbiological diagnostics, delaying antimicrobial treatment until after surgical sampling could be recommended, whenever possible. A heterogeneous selection of antimicrobial agents was reported, and precise data were frequently not extractable. Patients were generally started on antibiotics targeting the most likely causative organism while awaiting culture results.¹⁶,²²,⁵⁵,⁵⁸ Targeted antibiotic therapy was then continued for a variable duration, generally six weeks but sometimes longer.⁵,⁴⁸,⁵⁵,⁵⁸,⁶⁶ This reflects the need for personalised treatment in these challenging scenarios. Therefore, the selection of antibiotic therapy, along with its duration and administration method (oral and or intravenous), should be tailored to each individual case through a multidisciplinary consultation, and the post-operative follow up should also be conducted under the guidance of an infectious diseases specialist.⁹⁰

A purely conservative treatment (antibiotics only) was reported in only one patient of 149 carotid patch infections, who was deemed at high surgical risk.⁴⁸ Thus, inadequate data were available to support a totally conservative management strategy, and its adoption is not advised. Data were also insufficient to support carotid axis ligation or coil embolisation as a treatment option. Complete debridement of the surrounding infected tissue could be suggested, as it was performed in almost all cases after CEA patch infection (96.9% estimated proportion), ideally followed by reconstruction with autologous material. Infected material removal and autologous reconstruction appeared to reduce re-infection rates during follow up. Mann *et al.* reported infection free survival to be statistically significantly higher (93.5% vs. 47.1%; *p* = .007) when comparing these patients with those who underwent preservation or conservative treatment.⁵⁵ As an alternative, complete debridement associated with covered stent relining, followed by negative pressure wound therapy and tailored antibiotic therapy, could be considered.⁵³ Adjunctive procedures such as muscle flaps demonstrated their effectiveness in groin infections, and could also be considered in SAT infections, particularly if incomplete debridement and or material excision was obtained.⁹¹

Post-operative complications were fairly common (25.9%), and neurological complications particularly reported. Cranial nerve injury occurred in a non-negligible proportion (12.5%), which was substantially higher than the 5% after CEA performed for asymptomatic carotid stenoses.⁹²,⁹³ Furthermore, cranial nerve damage following CEA is usually described as transient, whereas approximately one third of these lesions were permanent in the current meta-analysis.⁹³

Re-infections were particularly infrequent during follow up, with an estimated proportion of 3.4% (95% CI 0.4 – 6.5%; $I^2$ = 0%; *p* = .66). This rate appears to be particularly low compared with other vascular territories, such as re-infections after aortic graft or endograft removal, where the reported rate may exceed 20%.⁹⁴,⁹⁵ There were no data supporting the use of adjunctive diagnostic investigations besides DUS, such as CT, MRI, or 18F-FDG PET-CT, during follow up if no clinical or laboratory signs of infection are present. Re-interventions during follow up after treatment for CEA with patch closure infection were low (3.4%), and were similarly low following SAT stent infections, with re-intervention reported in only one of 21 cases.⁷ Most of these re-interventions were similar to those performed after primary CEA, such as for re-stenosis or false aneurysm development.

## Limitations

The main limitation of this study was the scarcity of published works on the subject and their design. A meta-analysis was only possible for carotid patch infections. Furthermore, due to the lack of comparative studies among the included studies, a two group meta-analysis was not feasible. Therefore, a single group meta-analysis of proportions was conducted. Vascular prosthetic graft infections and infections after endovascular treatments of the SATs have rarely been reported in the literature, and the great majority of studies were case reports or very small case series. All of the included studies were retrospective, which may reflect the rarity of these conditions. This also contributed to the heterogeneity observed in most analyses and the wide confidence intervals, which may have reduced the precision of the population estimates. The high heterogeneity of some of the data, particularly regarding different treatments and probably attributable to non-standardised management, could have reduced the reliability of the results, even though a random effects model was adopted. Egger's test for publication bias was significant for mean time elapsed from intervention to patient presentation and for follow up length. However, the funnel plot asymmetry was probably attributable to true heterogeneity. Another possible limitation related to the reported infection rate, which was low but may still be overestimated as this study included articles focusing on graft infections. Finally, the diagnosis of infection was as reported by each study's authors. While the studies consistently referenced clinical and radiological evaluation for diagnosis, the lack of explicit definitions or uniform diagnostic criteria introduced variability that could have influenced the generalisability of the findings.

## Conclusions

Infections of vascular grafts and endografts in the SATs were rare but often symptomatic, with local signs after open procedures and systemic signs following stent infections. The preferred treatment for CEA patch infections involved removal of the infected prosthetic material followed by autologous reconstruction, which has been shown to result in satisfactory survival rates and a low risk of re-infection. Drainage and possibly relining with a covered stent,
combined with antibiotic therapy, offer a viable alternative. Cranial nerve injuries were common after surgery for CEA patch infections, with a third resulting in permanent damage. The re-infection rate during follow up was low.

## CONFLICTS OF INTEREST

The authors declare no potential conflicts of interest with respect to the research, authorship, and or publication of this article.

## FUNDING

None.

## APPENDIX A. SUPPLEMENTARY DATA

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ejvs.2025.05.006.

## REFERENCES

1. Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, et al. Editor's Choice – European Society for Vascular Surgery (ESVS) 2023 clinical practice guidelines on the management of atherosclerotic carotid and vertebral artery disease. *Eur J Vasc Endovasc Surg* 2023;65:7–111.

2. Lazarides MK, Christaina E, Argyriou C, Georgakarakos E, Tripsianis G, Georgiadis GS. Editor's Choice – Network meta-analysis of carotid endarterectomy closure techniques. *Eur J Vasc Endovasc Surg* 2021;61:181–90.

3. Oderich GS, Panneton JM, Cherry KJ, Hofer JM, Johnson CH, Olsen KD, et al. Carotid artery reconstruction combined with myocutaneous flap coverage: a complex and durable rescue operation. *Ann Vasc Surg* 2002;16:579–85.

4. Dougherty MJ, Calligaro KD, DeLaurentis DA. Infected false aneurysm after carotid endarterectomy: a case report and review of the literature. *Vasc Surg* 1997;31:791–6.

5. Asciutto G, Geier B, Marpe B, Hummel T, Mumme A. Dacron patch infection after carotid angioplasty. A report of 6 cases. *Eur J Vasc Endovasc Surg* 2007;33:55–7.

6. Menna D, Ruggiero M, Speziale F. Infected pseudoaneurysm after carotid endarterectomy: mismatch between clinical presentation and origin. *Ann Vasc Surg* 2014;28:740.e17–19.

7. Oweis Y, Gemmete JJ, Chaudhary N, Pandey A, Ansari S. Delayed development of brain abscesses following stent-graft placement in a head and neck cancer patient presenting with carotid blowout syndrome. *Cardiovasc Intervent Radiol* 2011;34(Suppl. 2):S31–5.

8. Chakfé N, Diener H, Lejay A, Assadian O, Berard X, Caillon J, et al. Editor's Choice – European Society for Vascular Surgery (ESVS) 2020 clinical practice guidelines on the management of vascular graft and endograft infections. *Eur J Vasc Endovasc Surg* 2020;59:339–84.

9. Thorbjörnsen K, Djavani Gidlund K, Björck M, Kragsterman B, Wanhainen A. Editor's Choice – Long-term outcome after EndoVAC hybrid repair of infected vascular reconstructions. *Eur J Vasc Endovasc Surg* 2016;51:724–32.

10. Lejay A, Koncar I, Diener H, de Ceniga MV, Chakfé N. Post-operative infection of prosthetic materials or stents involving the supra-aortic trunks: a comprehensive review. *Eur J Vasc Endovasc Surg* 2018;56:885–900.

11. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. *BMJ* 2021;372:n71.

12. Munn Z, Barker TH, Moola S, Tufanaru C, Stern C, McArthur A, et al. Methodological quality of case series studies: an introduction to the JBI critical appraisal tool. *JBI Evid Synth* 2020;18: 2127–33.

13. Schünemann HJ, Higgins JPT, Vist GE, Glasziou P, Akl EA, Skoetz N, et al. Chapter 14: Completing ‘Summary of findings’ tables and grading the certainty of the evidence [last updated August 2023]. In: *Cochrane Handbook for Systematic Reviews of Interventions version 6.5 (updated August 2023)* (Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, eds). Cochrane; 2024. Available at: [cochrane.org/handbook](https://cochrane.org/handbook) [Accessed 1 April 2025].

14. Wallace BC, Dahabreh IJ, Trikalinos TA, Lau J, Trow P, Schmid CH. Closing the gap between methodologists and end-users: R as a computational back-end. *J Stat Softw* 2012;49: 1–15.

15. Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. *BMC Med Res Methodol* 2005;5:13.

16. Stone PA, Srivastava M, Campbell JE, Mousa AY, Hass SH, Kazmi H, et al. A 10-year experience of infection following carotid endarterectomy with patch angioplasty. *J Vasc Surg* 2011;53: 1473–7.

17. Lin M, Drucker C, Gu J, Nagarsheth K, Toursavadkohi S. Autogenous femoral vein for secondary repair of subclavian arteries: a salvage solution for complex clinical scenarios. *Ann Vasc Surg* 2020;67:566.e5–9.

18. Chaudhuri A, Jayaweera S, Phatouros CC, Baker SR. Balloon occlusion of the internal carotid artery: a successful trial prior to arterial ligation/excision for an infected carotid patch. *EJVS Extra* 2007;13:66–8.

19. Haddad F, Wehbe M-R, Hmedeh C, Homsi M, Nasreddine R, Hoballah JJ. Bilateral carotid patch infection occurring 12 years following endarterectomy. *Ann Vasc Surg* 2020;65:285.e11–15.

20. Chang F-C, Lirg J-F, Tai S-K, Luo C-B, Teng MMH, Chang C-Y. Brain abscess formation: a delayed complication of carotid blowout syndrome treated by self-expandable stent-graft. *AJNR Am J Neuroradiol* 2006;27:1543–5.

21. Abdelhamid MF, Wall ML, Vohra RK. Carotid artery pseudoaneurysm after carotid endarterectomy: case series and a review of the literature. *Vasc Endovascular Surg* 2009;43:571–7.

22. Naughton PA, Garcia-Toca M, Rodriguez HE, Pearce WH, Eskandari MK, Morasch MD. Carotid artery reconstruction for infected carotid patches. *Eur J Vasc Endovasc Surg* 2010;40: 492–8.

23. Desai JA, Husain SF, Islam O, Jin AY. Carotid artery stent infection with *Streptococcus agalactiae*. *Neurology* 2010;74:344.

24. Varetto G, Trevisan A, Barile G, Gibello L, Spalla F, Frola E, et al. Carotid pseudoaneurysm after eversion endarterectomy: a case report and review of the literature. *Vasc Endovascular Surg* 2018;52:309–12.

25. Small C, Thompson T, Scali S, Berceli S, Cooper M, Back M, et al. Carotid stent explant indications and outcomes. *Ann Vasc Surg* 2021;77:1–6.

26. Son S, Choi N-C, Choi DS, Cho OH. Carotid stent infection: a rare but potentially fatal complication of carotid artery stenting. *BMJ Case Rep* 2014;2014:bcr2014011143.

27. Kovacevic P, Velicki L, Ivanovic V, Kieffer E. Carotid–carotid bypass as an option in the treatment of infected pseudoaneurysm after prosthetic carotid replacement. *Ann Vasc Surg* 2013;27:239. e13–16.

28. Tallarita T, Rogers RT, Bower TC, Stone W, Farres H, Money SR, et al. Characterization and surgical management of aberrant subclavian arteries. *J Vasc Surg* 2023;77:1006–15.

29. Younis G, Reul GJ, Krajcer Z. Combined endovascular and surgical treatment of infected carotid–carotid bypass graft. *J Endovasc Ther* 2006;13:687–92.

30. Torres-Blanco Á, Altable-García M, Miralles-Hernández M. Conservative surgical management of late carotid patch infection in a patient with subsequent stenting for restenosis. *Vasc Endovascular Surg* 2022;56:112–16.

31. Tabiei A, Cifuentes S, Colglazier JJ, Shuja F, Kalra M, Mendes BC, et al. Cryopreserved arterial allografts vs autologous vein for
arterial reconstruction in infected fields. *J Vasc Surg* 2024;79:941–7.

32 Rizzo A, Hertzer NR, O'Hara PJ, Krajewski LP, Beven EG. Dacron carotid patch infection: a report of eight cases. *J Vasc Surg* 2000;32:602–6.

33 Krishnan S, Clowes AW. Dacron patch infection after carotid endarterectomy: case report and review of the literature. *Ann Vasc Surg* 2006;20:672–7.

34 Knight BC, Tait WF. Dacron patch infection following carotid endarterectomy: a systematic review of the literature. *Eur J Vasc Endovasc Surg* 2009;37:140–8.

35 Simental A, Johnson JT, Horowitz M. Delayed complications of endovascular stenting for carotid blowout. *Am J Otolaryngol* 2003;24:417–19.

36 Ioku T, Imai K, Yamada T, Cho M, Sai T, Kato T. Delayed stent infection after deployment of a carotid dual layer stent in dialysis cases. *J Neuroendovasc Ther* 2024;18:126–9.

37 Pruitt A, Dodson TF, Najibi S, Thourani V, Sherman A, Cloft H, et al. Distal septic emboli and fatal brachiocephalic artery mycotic pseudoaneurysm as a complication of stenting. *J Vasc Surg* 2002;36:625–8.

38 Briguori C, Selvetella L, Baldassarre MP. Endovascular repair of a carotid pseudoaneurysm with Fluency Plus stent graft implantation. *J Invasive Cardiol* 2007;19:E254–7.

39 Baril DT, Ellozy SH, Carroccio A, Patel AB, Lookstein RA, Marin ML. Endovascular repair of an infected carotid artery pseudoaneurysm. *J Vasc Surg* 2004;40:1024–7.

40 Troutman DA, Mohan CR, Samhouri FA, Sohn RL. Endovascular repair of carotid artery pseudoaneurysm after carotid endarterectomy with self-expanding covered stents – a long-term follow-up. *Ann Vasc Surg* 2010;24:954.e13–16.

41 Bannazadeh M, Sattari AR, Skripochnik E, Tzavellas G, Tassiopoulos A. Endovascular repair of infected carotid pseudoaneurysm: a case report. *Int J Surg Case Rep* 2020;72:163–5.

42 Bates MC, Almehmi A. Fatal subclavian stent infection remote from implantation. *Catheter Cardiovasc Interv* 2005;65:535–9.

43 Wang K, Mohan IV. Hybrid repair of infected carotid patch. *Eur J Vasc Endovasc Surg* 2022;63:767.

44 Kaviani A, Ouriel K, Kashyap VS. Infected carotid pseudoaneurysm and carotid-cutaneous fistula as a late complication of carotid artery stenting. *J Vasc Surg* 2006;43:379–82.

45 Myles O, Thomas WJ, Daniels JT, Aronson N. Infected endovascular stents managed with medical therapy alone. *Catheter Cardiovasc Interv* 2000;51:471–6.

46 Motte S, Wautrecht JC, Bellens B, Vincent G, Dereume JP, Delcour C. Infected false aneurysm following carotid endarterectomy with vein patch angioplasty. *J Cardiovasc Surg (Torino)* 1987;28:734–6.

47 El-Sabrous R, Reul G, Cooley DA. Infected postcarotid endarterectomy pseudoaneurysms: retrospective review of a series. *Ann Vasc Surg* 2000;14:239–47.

48 Alawy M, Tawfick W, ElKassaby M, Shalaby A, Zaki M, Hynes N, et al. Late Dacron patch inflammatory reaction after carotid endarterectomy. *Eur J Vasc Endovasc Surg* 2017;54:423–9.

49 Le L, Charlton-Ouw K, Safi HJ, Azizzadeh A. Late expulsion of a Dacron patch after carotid endarterectomy. *J Vasc Surg* 2012;56:1721–3.

50 Byer A, Keys RC, Panush D, Frank E. Late infection of a Dacron carotid endarterectomy patch—a case report. *Vasc Surg* 2001;35:469–72.

51 Nayeemuddin M, Bhogal RH, Hickey N. Late presentation of an infected carotid patch as a superficial wound nodule. *Surg Infect (Larchmt)* 2008;9:395–7.

52 Lewis AK, Reeves M, Gaines PA, Beard JD. Late pseudoaneurysm following carotid patch infection. *Eur J Vasc Endovasc Surg* 2005;29:539–41.

53 Shehab M, Thorbjørnsen K, Mani K, Björck M, Wanhainen A. Long term outcome after EndoVAC hybrid repair of carotid patch infection. *Eur J Vasc Endovasc Surg* 2024;67:352–3.

54 McCready RA, Bryant MA, Fehrenbacher JW, Beckman DJ, Coffey AC, Corvera JS, et al. Long-term results with cryopreserved arterial allografts (CPAs) in the treatment of graft or primary arterial infections. *J Surg Res* 2011;168:e149–53.

55 Mann CD, McCarthy M, Nasim A, Bown M, Dennis M, Sayers R, et al. Management and outcome of prosthetic patch infection after carotid endarterectomy: a single-centre series and systematic review of the literature. *Eur J Vasc Endovasc Surg* 2012;44:20–6.

56 Xu JH, Altaf N, Tosenovsky P, Mwipatayi BP. Management challenges of late presentation Dacron patch infection after carotid endarterectomy. *BMJ Case Rep* 2017;2017:0217221541.

57 Illuminati G, Calio' FG, D'Urso A, Ceccanei G, Pacilè MA. Management of carotid Dacron patch infection: a case report using median sternotomy for proximal common carotid artery control and in situ polytetrafluoroethylene grafting. *Ann Vasc Surg* 2009;23:786.e1–5.

58 Fatima J, Federico VP, Scali ST, Feezor RJ, Berceli SA, Giles KA, et al. Management of patch infections after carotid endarterectomy and utility of femoral vein interposition bypass graft. *J Vasc Surg* 2019;69:1815–23.e1.

59 Graziotin MU, Strother CM, Turnipseed WD. Mycotic carotid artery pseudoaneurysm following stenting: a case report and lessons learned. *Vasc Endovascular Surg* 2002;36:397–401.

60 Robinson JN, Marturano MN, Calarese A, Briggs C, Madjarov J, Fisher DC, et al. Omental free flap coverage for extracavitary vascular bypass graft salvage. *Plast Reconstr Surg Glob Open* 2021;9:e3646.

61 Lazaris A, Sayers RD, Thompson M, Bell PRF, Naylor AR. Patch corrugation on duplex ultrasonography may be an early warning of prosthetic patch infection. *Eur J Vasc Endovasc Surg* 2005;29:91–2.

62 Furlough CL, Jain AK, Ho KJ, Rodriguez HE, Tomita TM, Eskandari MK. Peripheral artery reconstructions using cryopreserved arterial allografts in infected fields. *J Vasc Surg* 2019;70:562–8.

63 Borazjani BH, Wilson SE, Fujitani RM, Gordon I, Mueller M, Williams RA. Postoperative complications of carotid patching: pseudoaneurysm and infection. *Ann Vasc Surg* 2003;17:156–61.

64 Rockman CB, Su WT, Domenig C, Lamparello PJ, Adelman MA, Jacobowitz GR, et al. Postoperative infection associated with polyester patch angioplasty after carotid endarterectomy. *J Vasc Surg* 2003;38:251–6.

65 Grego F, Antonello M, Lepidi S, Bonvini S, Deriu GP. Prospective, randomized study of external jugular vein patch versus polytetrafluoroethylene patch during carotid endarterectomy: perioperative and long-term results. *J Vasc Surg* 2003;38:1232–40.

66 Naylor AR, Payne D, London NJM, Thompson MM, Dennis MS, Sayers RD, et al. Prosthetic patch infection after carotid endarterectomy. *Eur J Vasc Endovasc Surg* 2002;23:11–16.

67 Graver LM, Mulcare RJ. Pseudoaneurysm after carotid endarterectomy. *J Cardiovasc Surg (Torino)* 1986;27:294–7.

68 Blanco-Ruiz M, Fernández-Pérez J, Yoldi R, Rodríguez R, Arjona-Padillo A. Pseudoaneurysm and prosthetic exposure: an exceptional complication of endarterectomy and carotid angioplasty. *Neurol Perspect* 2024;4:100151.

69 Litwinski RA, Wright K, Pons P. Pseudoaneurysm formation following carotid endarterectomy: two case reports and a literature review. *Ann Vasc Surg* 2006;20:678–80.

70 Matano F, Suzuki M, Mizunari T, Yamada T, Murai Y, Morita A. Radial artery graft for giant common carotid artery pseudoaneurysm after carotid artery stenting. *World Neurosurg* 2020;139:401–4.

71 Azouz V, Fahmy JN, Kornbau C, Petrinec D. Recurrent pseudoaneurysm after carotid endarterectomy. *J Vasc Surg Cases Innov Tech* 2019;5:128–31.

72 Hillman Terzian WT, Schadt S, Sheth SU. Right carotid-cutaneous fistula and right carotid pseudoaneurysm formation secondary to
a chronically infected polyethylene terephthalate patch. *Int J Crit Illn Inj Sci* 2018;8:48–51.

73 Fok KC, Chan YC, Law Y, Cheng SW. Septic carotid endarterectomy patch as a result of preoperative tooth extraction. *Ann Vasc Surg* 2018;50:299.e1–4.

74 Léonore F-T, Elsa F, David P-C, Ludovic C, Pascal B, Charles Henri M-A, et al. Short- and long-term outcomes following biological pericardium patches versus prosthetic patches for carotid endarterectomy: a retrospective bicentric study. *Ann Vasc Surg* 2021;72:66–71.

75 Nishizawa N, Ozaki T, Kidani T, Nakajima S, Kanemura Y, Nishimoto K, et al. Stent infection and pseudoaneurysm formation after carotid artery stent treated by excision and in situ reconstruction with polytetrafluoroethylene graft: a case report. *Surg Neurol Int* 2022;13:24.

76 Malek AM, Higashida RT, Reilly LM, Smith WS, Kang SM, Gress DR, et al. Subclavian arteritis and pseudoaneurysm formation secondary to stent infection. *Cardiovasc Intervent Radiol* 2000;23:57–60.

77 Modrall JG, Joiner DR, Seidel SA, Jackson MR, Valentine RJ, Clagett GP. Superficial femoral-popliteal vein as a conduit for brachiocephalic arterial reconstructions. *Ann Vasc Surg* 2002;16:7–23.

78 Liu X, Zhao Y, Zhao F, Guo S, Sun D. Surgical treatment of carotid artery stent infection: a case report. *J Int Med Res* 2021;49: 300060520987081.

79 Martin GH, Saqib NU, Safi HJ. Treatment of an infected, bovine pericardial carotid patch: excision and reconstruction with a superficial femoral arterial interposition graft. *Ann Vasc Surg* 2021;70:565.e1–5.

80 Zacharoulis DC, Gupta SK, Seymour P, Landa RA. Use of muscle flap to cover infections of the carotid artery after carotid endarterectomy. *J Vasc Surg* 1997;25:769–73.

81 Fields CE, Bower TC. Use of superficial femoral artery to treat an infected great vessel prosthetic graft. *J Vasc Surg* 2004;40:559–63.

82 Eiberg JP, Røder O, Stahl-Madsen M, Eldrup N, Qvarfordt P, Laursen A, et al. Fluoropolymer-coated Dacron versus PTFE grafts for femorofemoral crossover bypass: randomised trial. *Eur J Vasc Endovasc Surg* 2006;32:431–8.

83 Exton RJ, Galland RB. Major groin complications following the use of synthetic grafts. *Eur J Vasc Endovasc Surg* 2007;34:188–90.

84 Perini P, Gargiulo M, Silingardi R, Bonardelli S, Bellosta R, Bonvini S, et al. Twenty-two year multicentre experience of late open conversions after endovascular abdominal aneurysm repair. *Eur J Vasc Endovasc Surg* 2020;59:757–65.

85 Paget DS, Bukhari RH, Zayyat EJ, Lohr JM, Roberts WH, Welling RE. Infectibility of endovascular stents following anti-biotic prophylaxis or after arterial wall incorporation. *Am J Surg* 1999;178:219–24.

86 Stewart A, Eyers PS, Earnshaw JJ. Prevention of infection in arterial reconstruction. *Cochrane Database Syst Rev* 2006;2006: CD003073.

87 Mahmoodi Z, Salarzaei M, Sheikh M. Prosthetic vascular graft infection: a systematic review and meta-analysis on diagnostic accuracy of ¹⁸FDG PET/CT. *Gen Thorac Cardiovasc Surg* 2022;70: 219–29.

88 Ajdler-Schaeffler E, Scherrer AU, Keller PM, Anagnostopoulos A, Hofmann M, Rancic Z, et al. Increased pathogen identification in vascular graft infections by the combined use of tissue cultures and 16S rRNA gene polymerase chain reaction. *Front Med (Lausanne)* 2018;5:169.

89 Puges M, Pereyre S, Bérard X, Accoceberry I, Le Roy C, Stecken L, et al. Comparison of genus specific PCR and culture with or without sonication for microbiological diagnosis of vascular graft infection. *Eur J Vasc Endovasc Surg* 2018;56:562–71.

90 Revest M, Camou F, Senneville E, Caillon J, Laurent F, Calvet B, et al. Medical treatment of prosthetic vascular graft infections: review of the literature and proposals of a working group. *Int J Antimicrob Agents* 2015;46:254–65.

91 Shimbo K, Kawamoto H, Koshima I. Use of muscle flaps for salvage of groin wound infection following vascular surgery: a systematic review and meta-analysis. *Vasc Endovascular Surg* 2022;56:401–7.

92 Gasior SA, O'Donnell JPM, Davey M, Clarke J, Jalali A, Ryan É, et al. Optimal management of asymptomatic carotid artery stenosis: a systematic review and network meta-analysis. *Eur J Vasc Endovasc Surg* 2023;65:690–9.

93 Halliday A, Bulbulia R, Bonati LH, Chester J, Cradduck-Bamford A, Peto R, et al. Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy. *Lancet* 2021;398:1065–73.

94 Perini P, Gargiulo M, Silingardi R, Bonardelli S, Bellosta R, Piffaretti G, et al. Twenty-five year multicentre experience of explantation of infected abdominal aortic endografts. *Angiology* 2025;76:85–93.

95 Shu H, Wang X, Wang M, Ding Y, Cheng H, Wang R, et al. Surgical management of abdominal aortic graft infection: network meta-analysis. *BJS Open* 2024;8:zrad151.