Hybrid repair of ruptured infected anastomotic femoral pseudoaneurysms: Emergent stent-graft implantation and secondary surgical debridement

Hybrid Repair of Infected Femoral Artery Pseudoaneurysm: Stent Graft Placement and Artificial Graft Replacement

A femoral artery pseudoaneurysm is the most prevalent complication of femoral access due to the artery's accessibility and frequent use for catheterization and blood tests. An infected femoral artery pseudoaneurysm is often life-threatening and challenging to manage. A 70-year-old male with a history of tongue cancer treatments, including resection, lymph node dissection, and radiation chemotherapy, visited his previous physician for a fever and was prescribed oral antibiotics, but the fever persisted, accompanied by pain and a mass in the left groin. An enhanced CT revealed an infected pseudoaneurysm of the left femoral artery. The fever's etiology was unclear but likely stemmed from a blood draw from the femoral artery during a prior visit, resulting in a pseudoaneurysm that became infected. The patient was transferred to our hospital due to management challenges. Blood cultures from the previous hospital were positive, and laboratory tests indicated an active infection. The initial strategy was to continue antibiotic therapy to control the infection. After approximately a month of antibiotic treatment, blood cultures remained negative, and laboratory results improved significantly. However, the aneurysm had clearly enlarged, necessitating emergency surgery. Typically, surgical intervention requires opening the abdomen to replace the external iliac artery to its extent, a considerably invasive procedure for the patient. Thus, we opted for a hybrid treatment, implanting a stent graft from the external iliac artery to the proximal common femoral artery and replacing artificial blood vessels from there to the femoral artery bifurcation. The postoperative course was favorable. In this case, we provided the optimal treatment for the patient's condition, despite the impossibility of a radical cure due to the cancer's progression. We believe the infected pseudoaneurysm was adequately controlled, and the hybrid therapy is effective for patients who cannot endure more invasive treatments.

Damage control surgery: old concepts and new indications

PURPOSE OF REVIEW

While the principles of damage control surgery - rapid hemorrhage and contamination control with correction of physiologic derangements followed by delayed definitive reconstruction - have remained consistent, forms of damage control intervention have evolved and proliferated dramatically. This review aims to provide a historic perspective of the early trends of damage control surgery as well as an updated understanding of its current state and future trends.

RECENT FINDINGS

Physiologically depleted patients in shock due to both traumatic and nontraumatic causes are often treated with damage control laparotomy and surgical principles. Damage control surgery has also been shown to be safe and effective in thoracic and orthopedic injuries. Damage control resuscitation is used in conjunction with surgical source control to restore patient physiology and prevent further collapse. The overuse of damage control laparotomy, however, is associated with increased morbidity and complications. With advancing technology, catheter- and stent-based endovascular modalities are playing a larger role in the resuscitation and definitive care of patients.

SUMMARY

Optimal outcome in the care of the most severely injured patients requires judicious use of damage control surgery supplemented by advancements in resuscitation and surgical adjuncts.

Nahtaneurysmen - Ätiopathogenese, Symptomatologie, Diagnostik, Therapie, Outcome und Einflussfaktoren nach offen gefäßchirurgischer und interventioneller Rekonstruktion

Hintergrund Die über die letzten Jahre/Jahrzehnte ausgebaute und optimierte gefäßchirurgische Grundversorgung hat auch das Fallaufkommen von Sekundärkomplikationen wie das Nahtaneurysma (NA) wesentlich erhöht.

Ziel Darstellung der sekundären Versorgungsdiagnose NA in ihrem/r Fallaufkommen, Ätiopathogenese, Symptomatologie, Diagnostik, periinterventionellem/-operativem Management und Outcome, basierend auf selektiven Referenzen der medizinisch-wissenschaftlichen Literatur und eigenen klinischen Versorgungserfahrungen.

Methode Narratives Review

Ergebnisse

Schlussfolgerung Das NA als relevante Versorgungsgröße ist inzwischen längst mit in den Fokus eines basalen gefäßchirurgischen/-interventionellen Betreuungsprofils gerückt, dem sich der Gefäßchirurg/-interventionalist aufgrund der bestehenden Herausforderung hinsichtlich des anspruchsvollen diagnostischen und therapeutischen Managements mit seiner ganzen fachspezifischen Kompetenz widmen muss.

Persistent mycotic superficial femoral artery pseudoaneurysm after endovascular treatment: a case report

Mycotic pseudoaneurysms of the superficial femoral artery (SFA) are rare and are usually secondary to colonization of an atherosclerotic plaque during an episode of bacteremia. We describe the case of a 68 year-old diabetic male who presented to the Emergency Department with pyrexia and a painful expanding mass in the left thigh. He had a history of diarrhea and had been treated 16 days earlier for an SFA pseudoaneurysm that had been excluded with a covered stent with no adjunctive antibiotic therapy. Angio CT showed an abscess surrounding femoral vessels and stent thrombosis. Under general anesthesia, we performed extensive debridement, removal of the endovascular material, SFA ligation, and empirical antibiotic therapy. Blood and tissue cultures were positive for Escherichia coli. At the 3-months follow up visit, the patient reported he had no claudication. In selected patients, mycotic pseudoaneurysms can be treated by SFA ligation.

An Infected Popliteal Aneurysm after Plain Old Balloon Angioplasty

The case was a 76-year-old man with chronic limb-threatening ischemia. Plain old balloon angioplasty (POBA) was performed on the popliteal artery. Subsequently, he suffered from cellulitis around the POBA site, followed by reocclusion. Staphylococcus aureus was detected in a blood culture. After re-revascularization with POBA, both purulent gonitis and an infected popliteal aneurysm were observed to occur. We performed aneurysmectomy and bypass grafting with the saphenous vein and then continued antibiotic therapy. Although treatment consisted of endovascular therapy (EVT) with nothing left behind, management was difficult because of secondary infectious complications. We conclude that prophylactic antibiotics before EVT should be considered in such cases.

Graft Infection after Prosthetic Bypass Surgery for Infectious Femoral Artery Pseudoaneurysm in Intravenous Drug Users: Manifestation, Management, and Prognosis

BACKGROUND

The aim of this study is to assess the incidence, clinical manifestations, management, and prognosis of graft infection after bypass surgery with prosthetic conduit for infectious femoral artery pseudoaneurysms (IFAPs) in patients with a history of intravenous drug use (IVDU).

METHODS

A single-center retrospective chart review of IVDU presenting with graft infections after previously being treated with extra-anatomic prosthetic conduit bypass surgery for IFAPs between 2009 and 2019 was performed. Relevant clinical data and patient demographics were collected and analyzed. All patients underwent procedures consisting of graft removal with analysis of operative details and complications.

RESULTS

Of all 122 patients who underwent IFAP resection with extra-anatomic prosthetic bypass, the incidence of graft infection was 38.5% (47 patients, 48 grafts) with an average age of 35.7 ± 7.3 years. The average interval between bypass surgery and infectious symptoms was 9.2 ± 2.5 months and average time from bypass to graft removal was 13.6 ± 3.4 months. The most common presentation was repeated or unhealable chronic ulcers with sinus formation or purulence either within the bypass area or along the graft conduit route (43, 89.6%). Occlusion of the infected bypass graft occurred in nearly all cases (46, 95.8%). Severe hemorrhage occurred in only 1 case (2.1%). After graft removal, the stumps were ligated in the majority of patients (33, 68.8%) with 15 patients (31.2%) not amenable to ligation due to a difficult dissection. The average time of operation was 35.4 ± 8.7 min with an average blood loss of 35.8 ± 6.7 mL. There were no significant complications such as infection reoccurrence, severe limb ischemia, amputation, or death observed postoperatively.

CONCLUSIONS

Patients who receive bypass surgery with prosthetic conduit for IFAPs carry a high incidence of graft infection and subsequent occlusion. However, the presenting symptoms are generally mild, and the incidence of fatal complications is rare. This study suggests that a safe treatment option consists of direct graft removal without reconstruction. Additionally, the procedure proved to be relatively convenient and straightforward, which provides further support toward the strategy of treating IFAPs in IVDUs with pseudoaneurysm resection and prosthetic conduit bypass surgery.

Massive Scrotal Hematoma due to Ruptured Anastomotic Pseudoaneurysm in a Patient with Aortobifemoral Bypass Surgery: CTA Evaluation

A 74-year-old male patient was presented with scrotal swelling and a pulsatile mass of the left femoro-inguinal region. His medical history included hypertension, coronary artery disease, respiratory failure, and an aortobifemoral bypass surgery performed 7 years ago. Ultrasound evaluation revealed a massive scrotal hematoma. Computed tomography angiography (CTA) was conducted, confirming the aortobifemoral graft existence and revealing bilateral anastomotic pseudoaneurysms with the left one being ruptured, resulting in extension of the hematoma to the left femoro-inguinal region and the scrotum. An emergency surgery was performed, where proximal control of the left limb of the synthetic graft as well as distal control of the iliac vessels were accomplished. After the control of the hemorrhage, an iliofemoral bypass with a Polytetrafluoroethylene (PTFE) 6 mm synthetic graft was placed. Unfortunately, the patient passed away during the first postoperative day due to myocardial infarction.

Ruptured Superficial Femoral Artery Anastomotic Pseudoaneurysm after 30 Years

Introduction

Anastomotic pseudoaneurysms are a complication of vascular reconstructive surgery with the majority in the femoral region. Although rare, ruptured femoral anastomotic pseudoaneurysms have high mortality and require emergency surgery.

Case Presentation

A 60-year-old male with a history of a left leg crush injury was treated with a superficial femoral artery interposition vein graft 30 years ago. He presented nowadays with a three-day history of severe pain in his left thigh. CT angiography demonstrated a ruptured anastomotic pseudoaneurysm with contrast extravasation into an intramuscular hematoma. He had significant scarring from his previous surgeries which made the leg hostile for an open repair. Therefore, percutaneous access selectively cannulated the left iliofemoral vasculature. An angiogram showed a distal superficial femoral artery pseudoaneurysm. Subsequently, two 10mmx15cm Viabahn covered stents (Gore & Associates, Flagstaff, AZ) were placed bridging healthy superficial femoral artery. A completion angiogram demonstrated no extravasation into the pseudoaneurysm. The patient recovered and was discharged home two days postoperatively.

Conclusion

Ruptured femoral anastomotic pseudoaneurysms are traditionally repaired with open pseudoaneurysm excision and arterial reconstruction, although endovascular repair has been reported. Furthermore, most femoral anastomotic pseudoaneurysms form less than 10 years after initial operation. We present a unique case of ruptured superficial femoral artery pseudoaneurysm, 30 years after the initial operation. Endovascular stents offer effective treatment for ruptured anastomotic pseudoaneurysms.

Transradial stenting of a carotid pseudoaneurysm

Carotid pseudoaneurysms are rare and, if treated endovascularly, are usually approached via the femoral artery. We report the case of transradial stenting of an anastomotic carotid pseudoaneurysm secondary to vertebral transposition through an existing carotid-subclavian bypass.

Endovascular Treatment of Femoral Anastomotic Aneurysm: Case Report and Review of Published Cases

Anastomotic aneurysm is a possible complication after arterial reconstruction with highest incidence at femoral anastomosis; open surgery is the standard treatment, but endovascular exclusion can be useful in selected cases. The authors report a case of femoral anastomotic aneurysm, 19 years after aortobifemoral grafting, treated successfully using stent grafts, under local anesthesia and percutaneous brachial access. Review of published articles regarding endovascular management of femoral anastomotic aneurysm was performed. Endovascular exclusion of femoral anastomotic aneurysm is safe and feasible.

A staged, endovascular approach to treat a ruptured external iliac artery mycotic pseudoaneurysm in an intravenous drug user: A case report

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Initial hybrid approach to achieve haemorrhagic and sepsis control is a viable option as a bridge to delayed definitive arterial reconstruction .

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Endovascular stent-grafting provides an alternative treatment strategy to arterial ligation in cases of ruptured mycotic pseudoaneurysms.

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Anticipation of stent-graft infection can allow time to plan for delayed arterial reconstruction.

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Subsequent stent-graft removal and reconstruction can preclude complications of arterial ligation, including claudication and limb-loss.

Introduction

Ruptured mycotic pseudoaneurysms are one of the ways IVDU patients can present in extremis. The principles of treatment include arterial ligation for haemorrhage control but can leave patients vulnerable subsequent limb ischaemia.

Presentation of case

We report a female IVDU presenting with abdominal pain and sepsis. Imaging demonstrated haemorrhage from an external iliac pseudoaneurysm. A two-staged hybrid approach with initial endografting and debridement for sepsis-control followed by delayed endograft removal and arterial reconstruction was successfully undertaken.

Discussion

The primary use of endovascular techniques to control haemorrhage in unstable patients is a useful adjunct to treat ruptured mycotic pseudoaneurysms in IVDU patients with delayed removal and arterial reconstruction.

Conclusion

We have shown a successful outcome in managing a challenging patient using endovascular techniques as a bridge to definitive arterial reconstruction. This circumvents traditional approaches including primary arterial ligation, which carry a risk of limb-loss.

Damage Control Endografting for the Unstable or Unfit Patient

BACKGROUND

In the elective setting, both open surgical and endovascular therapies may be reasonable treatment options for many vascular conditions. However, an unstable or unfit patient with a vascular emergency may be less able to tolerate a definitive open vascular operation. We now report the outcomes for "damage control" endografting for unstable or unfit patients with vascular emergencies as bridge therapy before definitive open therapy.

METHODS

A retrospective review of patients who underwent damage control endografting over a 9-year period (2005-2014) was performed. The primary inclusion criterion was the use of emergency damage control endografting as temporizing therapy to permit time for patient stabilization or optimization before definitive open repair. Patients who underwent endografting as planned definitive therapy were excluded.

RESULTS

Indications for damage control endografting included arterial bleeding or expanding hematoma related to infected pseudoaneurysms (n = 5), infected grafts (n = 3), or cancer (n = 1). Anatomic locations included the aorta (n = 3), common iliac artery (n = 2), common femoral artery (n = 2), common carotid artery (n = 1), and subclavian artery (n = 1). The median age was 56 years (interquartile range [IQR] 51-70). Five of our patients were male and 4 patients were female. Median follow-up was 8 months (IQR 3-11). Operative (30-day) mortality was 11%. A single patient died on postoperative day 12 after undergoing aortic and duodenal reconstruction related to an aortoenteric fistula. Using the damage control approach, clinical stabilization was achieved in 8 of the 9 patients (88%). One patient with a bleeding infected common femoral artery pseudoaneurysm continued to bleed and required emergent open surgical repair. Definitive open repair was completed in 8 of the 9 patients (88%) at a median time interval of 3 days (IQR 1-10). Planned open repair was not performed in a patient with exsanguinating carotid hemorrhage after the associated cancer was deemed unresectable.

CONCLUSIONS

Damage control endografting facilitates stabilization of the majority of unstable and unfit patients with vascular emergencies to allow definitive open repair under more favorable conditions. This technique should be employed rarely due to the expense, but it is a technique worthy of consideration in select patients.

Emergency Hybrid Approach to Ruptured Femoral Pseudoaneurysm in HIV-positive Intravenous Drug Abusers

BACKGROUND

Chronic traumatism of the common femoral artery due to intravenous injection in drug abusers, in association with local infections and arterial wall weakening caused by human immunodeficiency virus (HIV), can lead to the development of pseudoaneurysms (PSAs). Rupture of PSA is a dramatic event in such patients, and its correction is difficult and controversial. Most of the cases reported describe open surgical elective options, which consist in ligation, repair, or substitution of the damaged arterial segment, using when possible biological grafts. In literature, few cases describe an endovascular repair with covered stent deployment.

METHODS

We present 2 cases of HIV-positive intravenous injection in drug abusers who needed emergency treatment for active bleeding in ruptured PSA of the right common femoral artery. In both cases, under general anesthesia needed for lack of patient's compliance and unstable hemodynamics, a short dissection to the distal superficial femoral artery was required.

RESULTS

Then, maintaining a manual compression on the bleeding site to stop hemorrhage, we deployed a covered stent graft in the site of the arterial breakdown through a retrograde approach.

CONCLUSIONS

The favorable results and progressive healing of wound and local infections persuaded us not to perform any further surgical correction. The absence of recurrences and late complications, after 3 years in the first case and 1 year in the second one, lead us to consider this hybrid endovascular approach as a valuable alternative to open surgery in HIV intravenous injection in drug abuser patients, in particularly when emergency conditions occur.

Endovascular Management of Infected Iliofemoral Pseudoaneurysms

The treatment of infected iliofemoral pseudoaneurysms is challenging and controversial. We present our experience regarding the efficacy and outcome of endovascular treatment of infected iliofemoral arterial pseudoaneurysms with covered stents. Our experience with 5 cases showed that stent grafting combined with antibiotic therapy and provisional drainage may be a safe and effective option in patients with cancer, patients with history of multiple hip revisions, and drug-addicted users. In our small case series, the reinfection rate was null and no covered stent thrombosis occurred. These results are fairly encouraging, but further studies with longer follow-up in a larger number of patients are needed to confirm the efficacy and durability of the technique.

Use of a hybrid polytetrafluoroethylene stent graft for iliofemoral bypass in the setting of femoral blow-out

Revascularization in the setting of anastomotic “blow-out” in the groin is a technically demanding and morbid undertaking, often mandating transabdominal or retroperitoneal exposure of the iliac artery for proximal control or anastomosis, or both. The Gore Hybrid Vascular Graft (W. L. Gore and Associates Inc, Flagstaff, Ariz) is an expanded polytetrafluoroethylene graft with an external nitinol stent on one end designed for remote venous implantation for proximal axillary vein dialysis access outflow. We recently used this device to treat femoral anastomotic disruptions in two postoperative patients.

Aneurysm Formation and Infection in AV Prosthesis

In contrast to autogenous arteriovenous (AV) fistulae where true aneurysms are the most frequent type, aneurysms in prosthetic AV grafts are mostly false aneurysms and less frequently anastomotic ones. Indications for repair comprise false aneurysms exceeding twofold the graft diameter, those with rapid enlargement or with skin thinning or erosion, the ruptured, those causing pain or severely limiting the cannulable area and the infected ones. They can be managed either with conventional surgery or with endovascular techniques; However, conventional surgery represents the current standard treatment consisting of either aneurysm resection and interposition graft in situ or resection/exclusion and bypass via a new route to avoid a potentially contaminated area.

Ruptured mycotic common femoral artery pseudoaneurysm: fatal pulmonary embolism after emergency stent-grafting in a drug abuser

The rupture of a mycotic femoral artery pseudoaneurysm in an intravenous drug abuser is a limb- and life-threatening condition that necessitates emergency intervention. Emergency stent-grafting appears to be a viable, minimally invasive alternative, or a bridge, to subsequent open surgery. Caution is required in cases of suspected concomitant deep vein thrombosis in order to minimize the possibility of massive pulmonary embolism during stent-grafting, perhaps by omitting stent-graft postdilation or by inserting an inferior vena cava filter first. We describe the emergency endovascular management, in a 60-year-old male intravenous drug abuser, of a ruptured mycotic femoral artery pseudoaneurysm, which was complicated by a fatal pulmonary embolism.

Stent-graft placement with early debridement and antibiotic treatment for femoral pseudoaneurysms in intravenous drug addicts

PURPOSE

Explore the application of endovascular covered stent-graft (SG) placement in femoral pseudoaneurysms in intravenous drug addicts.

MATERIALS AND METHODS

We evaluated a consecutive series of pseudoaneurysm in intravenous drug addicts treated with SGs from August 2010 to December 2013.

RESULTS

15 patients with 16 arterial pseudoaneurysms were enrolled in this study. All were males with a mean age of 36.9 years. Hemorrhage was the most common reason (93.8 %) for seeking medical care, and 3 of these patients were in hemorrhagic shock at admission. All patients received broad-spectrum antibiotics, and debridement and drainage were implemented after SG placement. 7 of the 13 cases which had microbiologic results showed mixed infections, while gram-negative bacteria were the major pathogens. Except for 2 patients, who were lost to follow-up, two new pseudoaneurysms formed due to delayed debridement, and one stent thrombosis occurred, none of the remaining cases had SG infection or developed claudication.

CONCLUSIONS

SG placement controls massive hemorrhage rapidly, gives enough time for subsequent treatment for pseudoaneurysms due to intravenous drug abuse, and reduces the incidence of postoperative claudication. With appropriate broad-spectrum antibiotics and early debridement, the incidence of SG infection is relatively low. It is an effective alternative especially as temporary bridge measure for critical patients. However, the high cost, uncertain long-term prospects, high demand for medical adherence, and the risk of using the conduits for re-puncture call for a cautious selection of patients. More evidence is required for the application of this treatment.

Management of a complicated ruptured infected pseudoaneurysm of the femoral artery in a drug addict

Infected pseudoaneurysm of the femoral artery represents a devastating complication of intravenous drug abuse, especially in the event of rupture. Operative strategy depends upon the extent of arterial injury and the coexistence of infection or sepsis. Options range from simple common femoral artery (CFA) ligation to complex arterial reconstruction with autologous grafts (arterial, venous, or homografts). We report herein the management of a 29-year-old male patient who was urgently admitted with a ruptured pseudoaneurysm of the right CFA, extending well above the inguinal ligament. Multidisciplinary approach with multiple arterial reconstructions and subsequent coverage of the tissue defect with a rectus abdominis musculocutaneous flap transposition was performed.

Salmonella-related mycotic pseudoaneurysm of the superficial femoral artery

INTRODUCTION

Mycotic pseudoaneurysms of native arteries are rare. Treatment involves arterial excision with or without revascularization.

PRESENTATION OF CASE

A 49-year-old diabetic man presented with a 4-month history of progressive left mid-thigh pain, associated with a pulsatile mass and fever. Clinically, he appeared to have a mycotic pseudoaneurysm, which was confirmed by computed tomography. The aneurysm was excluded from the circulation by an extra-anatomical bypass graft using autologous vein.

CONCLUSION

Native arterial mycotic pseudoaneurysms typically occur in immuno-compromised patients. They may be successfully treated using autologous vein bypass.

DISCUSSION

Arterial infection is associated with immunosuppressive states and Staphylococcus aureus is the most commonly isolated organism in mycotic aneurysms. Also, Escherichia coli, Salmonella sp. and anaerobic species have been identified. Salmonella species are associated with mycotic aneurysms in the abdominal aorta and the use of autogenous vein grafts is the standard treatment for this condition. In lower extremities, autogenous conduits have been already used with good results of patency and freedom from re-infection. Endovascular treatment is a feasible approach in these situations, but there is not reports regarding long term results and this treatment is occasionally associated with prosthesis infection.

Gram-negative groin sepsis treated with covered stents and systemic antibiotics

Prosthetic graft infections are hazardous conditions. Those due to Gram-negative bacteria are particularly serious. When Gram-negative microorganisms are present, entire graft excision is recommended, with revascularization if needed, preferably with autogenous tissues or with prosthetic grafts via non-infected planes if autogenous options are not available. We herein report the case of a diabetic man with critical limb ischemia, who after lower-extremity revascularization with a prosthetic graft, developed an early graft infection due to Gram-negative and fungal organisms, and who was successfully treated with a covered stent placed across grossly infected tissues. A discussion on the pertinent literature is also offered.

Treatment of a recurrent false aneurysm of the femoral artery by stent--graft placement from the brachial artery

An anastomotic false aneurysm is a well known complication after femoral artery surgery. Open surgical repair is the treatment of choice for anastomotic femoral aneurysms, but this can be challenging, unsuccessful, or even impossible. Endovascular repair is an alternative in these cases, but the delivery of a stent--graft in the femoral artery can be difficult. We report the case of a patient with a recurrent left femoral artery anastomotic false aneurysm, treated twice by open exclusion, and finally excluded successfully by a stent--graft that was inserted through the left brachial artery.