Challenging management of infected central venous stents complicated by pseudoaneurysm in dialysis: A case report

Stent placement for venous stenosis is common in patients with arteriovenous fistulas. However, infection of a central venous stent with subsequent brachiocephalic pseudoaneurysm formation presents a complex and high-risk scenario. While infected graft removal is ideal, management is challenging due to difficulties in extracting deep stents, irrigating the infected focus, and handling infected pseudoaneurysms. Documented experience on managing such conditions is lacking. A 64-year-old female maintenance hemodialysis patient with a dialysis vintage of 3.5 years, currently using a right jugular tunneled catheter, had received eight sequential stents from the left innominate to axillary vein for recurrent central venous stenosis. One month before admission, an infection developed in the left axillary region, involving the peri-stent space around the axillary venous stents. Computed tomography (CT) angiography revealed extensive peri-stent purulence eroding into the brachiocephalic artery, forming a pseudoaneurysm. The patient had a left ventricular ejection fraction (LVEF) of 31%. Enterobacter cloacae was cultured. Limited debridement was performed via an axillary approach: loosened stents were removed, deeper stents were left in place, and the pseudoaneurysm was not directly addressed. To minimize systemic spread and heart failure exacerbation, a "manual low-pressure drip-and-gentle aspiration" technique was used for irrigation and drainage with normal saline only, avoiding continuous suction. Postoperatively, septic symptoms resolved, infection parameters improved, and the pseudoaneurysm remained stable. The patient was discharged with a partially retained stent and drainage tube on long-term antibiotics. For patients with central venous stent infection and poor physiological reserve, "palliative debridement with restricted drainage" is a feasible salvage approach. This case highlights the catastrophic potential of infection after long-segment central venous stenting, underscoring the paramount importance of prevention.