Introduction: Common femoral artery (CFA) endarterectomy and patch profundoplasty is a common procedure for vascular surgeons, either in isolation or associated with proximal/distal endovascular treatment. However, this is not without risk of significant complications. Biological patches (BPs) are considered more resistant to infection and a durable alternative to saphenous vein for arterial reconstruction. BP infections, despite being a poorly reported sequela, represent a challenging scenario. The management of an infected BP may be even more complex in the emergency setting with acute blowout of the patch and pre-existing iliac stents protruding distal to the inguinal ligament into the patch. A combined approach utilising the full arsenal of endovascular and open surgery is likely the safest and quickest repair strategy. We present the hybrid management of a limb/life threatening postoperative CFA bleed secondary to bovine pericardium patch infection, dehiscence, and rupture.
Case description: A 67 year old male presented acutely with a postoperative right groin infected haematoma (Fig. 1A). He previously underwent a hybrid revascularisation procedure for severely impaired short distance claudication by means of common femoral endarterectomy, BP profundoplasty, and concomitant full length external iliac recanalisation (outback re-entry technique and 10 mm diameter nitinol self-expandable stent intentionally deployed extending below to the inguinal ligament, protruding into the patch). The initial procedure was uneventful. He then re-presented to the emergency department three months after surgery with sudden onset pain and a pulsatile swelling in his right groin. The patient was haemodynamically unstable with raised inflammatory markers and fever. Computed tomography angiography revealed active bleeding secondary to a suspected blow out of the patch resulting in a 9 cm haematoma with overlying threatened skin. This was also associated with Rutherford class 2b acute limb ischaemia and skin mottling of the right foot. The patient was taken to theatre for emergency hybrid intervention. (1)
Endovascular stage: contralateral left CFA ultrasound guided retrograde puncture; “up and over” approach, and right in stent 10 mm × 40 mm balloon inflation for inflow control. Cannulation of right profunda femoris artery (PFA) with a standard Terumo wire, subsequently exchanged to a stiff SupraCore wire, with the view of providing an anatomical landmark (Fig. 2A, B). (2) Open Surgical stage: right vertical groin incision exposed a disintegrated BP with a disrupted suture line. In the context of significantly altered anatomy, the PFA was dissected using the wire as a reference point (Fig. 1B). Backflow control was achieved by clamping of PFA distal to the third divisional branch (chronic superficial femoral artery occlusion). An interposition graft from the right CFA to PFA was fashioned using reversed ipsilateral long saphenous vein (Fig. 1C). A sartorius muscle flap was shaped to cover the graft (Fig. 1D). Completion angiography confirmed a good technical outcome with preserved inflow and outflow via the PFA (Fig. 2C, D). The patient recovered well postoperatively with good perfusion of the lower limb and restored neurological function. Specimen cultures grew Streptococcus dysgalactiae, treated with vancomycin.
Discussion: The hybrid approach allows for safer management of catastrophic CFA bleeding secondary to blowout of an infected patch. An endovascular approach may facilitate iliac inflow control, expedite PFA dissection, and haemostasis in an anatomically disrupted groin. The “up and over” balloon technique for haemostasis negated direct clamping of the previous iliac stent, possibly avoiding inflow complications. Autologous vein interposition graft for revascularisation of the acutely threatened limb remains the safest demonstrated strategy in an infected surgical field. Sartorius muscle flap is an effective way to protect the vascular reconstruction in the foreseen event of further soft tissue sequelae (residual soft tissue infection and demarcating skin necrosis).
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