Bio-synthetic Graft Repair of Mycotic Aneurysm of the Common Femoral Artery
Article Outline
Abstract
Mycotic aneurysms of the common femoral artery are rare. They usually occur in intravenous (IV) drug abusers using the femoral vessels for injection. Treatment options are limited due to high graft-infection rates. We describe the first use of a bio-synthetic graft, ilio-femoral bypass, for an infected aneurysm caused by an IV drug abuse.
Keywords: Mycotic aneurysms, Intravenous drug abuse, Bio-synthetic graft (Omniflow II)
Case Report
A 36-year-old male intravenous drug user (IVDU) presented with a pulsatile left groin mass and pyrexia (Fig. 1). Distal pulses were normal. Duplex scan revealed a 1.5-cm false aneurysm of the common femoral artery above its bifurcation, confirmed by blood cultures growing Candida species. Venous imaging showed extensive bilateral deep vein thrombosis (DVT) and occluded long saphenous veins.
Figure 1
Mycotic aneurysm pointing on to the skin.
Antibiotic treatment, with intravenous (IV) Cefuroxime, Metronidazole and Fluconazole (hospital guidelines), was commenced immediately. The aneurysm expanded over the next 4 days to a size of 2.7
cm on ultrasound, surrounded by a collection. This initiated surgical intervention. At anaesthetic induction, the aneurysm occluded, causing acute limb ischaemia. The external iliac and superficial femoral arteries were ligated to de-vascularise the aneurysm. An ilio-femoral bypass was performed using a bio-synthetic (Omniflow II, Bio Nova) graft due to the extensive local sepsis and extensive DVT. Distal circulation returned to normal.
Five days later, the patient began mobilising and was discharged from the hospital. On first follow-up appointment at 6 weeks, the groin mass had reduced significantly in size. The graft was pulsatile and foot pulses were all palpable. Follow-up at 6 months with a duplex scan showed a patent graft with good inflow and patent outflow vessels.
Discussion
Mycotic aneurysms are rare. The most common cause is IV drug abuse. Other causes include septic embolisation, extension from local infection or trauma. The prevalence rate is 0.03% in IVDUs.1 Complications include systemic sepsis, local extension of infection, vessel rupture and arterial occlusion leading to limb ischaemia.
Treatment consists of arterial ligation with or without re-vascularisation. Long-term follow-up after ligation alone demonstrates a high risk of chronic limb ischaemia2 with ABIs ranging from 0.41 to 0.58.
Autologous extra-anatomical bypass is challenging in intravenous drug abusers with poor availability of suitable vein. Extra-anatomical bypass with polytetrafluoroethylene (PTFE) or Dacron is usually avoided in favour of ligation due to the high rates of infection.3 Endovascular stent-grafting of infected aneurysms has also been described, but the longer-term durability of this approach is unclear. Strict compliance with close monitoring of the stent-graft is essential,4 but rarely possible in such patients.
The procedure we describe here uses a bio-synthetic graft. The Omniflow graft is a composite of an endoskeleton polyester mesh and ovine/sheep collagen that is designed to provide the dual benefits of durability from synthetic material and haemocompatible flow from the use of biological material (Fig. 2). Studies in renal access have shown infection rates from 0% to 3.4%,5 as compared to 3% and 13% with PTFE and Dacron, respectively, when used extra-anatomically.
Figure 2
Omniflow graft in situ after anastamosis.
Bio-synthetic material is also an attractive long-term option due to its bio-compatibility allowing the integration of the graft into host tissues as well as true micro-vascularisation of the graft vessel wall.
The use of bio-synthetic prostheses for arterial bypass surgery and AV fistulas in haemodialysis patients has been well described. We believe that this is the first described case of a bio-synthetic graft used for a patient with a mycotic aneurysm.
Conclusions
Current surgical options for the treatment of mycotic aneurysms consist of arterial ligation and later re-vascularisation, if necessary, using extra-anatomical bypass with autologous or prosthetic grafts.
In this article, we have described the combined approach of vessel ligation in continuity and the use of a bio-synthetic graft to restore circulation. This may be a better alternative to current surgical therapy. Our method avoids the isolated ligation of vessels, which often leads to post-procedure limb ischaemia. There is less need for secondary re-vascularisation thus reducing the need for multiple surgical interventions.
Further experience and long-term follow-up is needed to establish this as a viable option for the surgical treatment of mycotic aneurysms.
Conflict of Interest
None.
References
- . Presentation diagnosis and management of arterial mycotic pseudoaneurysms in injection drug users. Annals of Vascular Surgery. 2002;16(5):652–662
- . Vascular complications of drug abuse: an Indian experience. Australian and New Zealand Journal of Surgery. 2003;73(12):1004–1007
- . Axillobifemoral bypass and aortic exclusion for vascular septic lesions: a multicentre retrospective study of 98 cases. Annals of Vascular Surgery. 1992;6(2):119–126
- . Endoprosthetic treatment of a mycotic superficial femoral artery aneurysm. J Endovasc Ther. 2003 Aug;10(4):843–845
- . Analysis of 274 Omniflow vascular prosthesis implanted over an eight year period. Australian and New Zealand Journal of Surgery. 1996;67(9):637–639
PII: S1533-3167(08)00030-7
doi:10.1016/j.ejvsextra.2008.11.003
© 2008 European Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Biosynthetic Graft Repair of Mycotic Aneurysm of the Common Femoral Artery , 11 May 2009
