IP215. Mature Radiocephalic Fistula as Conduit for Bypass of a Mycotic Common Femoral Artery Pseudoaneurysm: A Case Report

Abstract

Mycotic common femoral artery pseudoaneurysms are a challenging entity with high morbidity. Surgical intervention has been described in intravenous drug abusers. Ligation of the infected pseudoaneurysm and revascularization often result in limb amputation or other complications. This case report describes the safety and efficacy of novel limb preservation surgery using an arteriovenous fistula as a robust conduit. A 59-year-old woman with history of end-stage renal disease, diabetes mellitus, and peripheral vascular disease presented status post cardiac catheterization with a right mycotic common femoral artery pseudoaneurysm measuring 2.3 × 1.8 × 2.3 cm. Preoperative vein mapping revealed no suitable superficial veins for graft harvesting, given the need to support a high-flow area. Blood culture specimens grew Pseudomonas aeruginosa, and antibiotics were initiated. Taking into account the need for permanent vascular access for dialysis in the future, deep veins were not harvested. The patient's radiocephalic fistula was created 6 months earlier and was functioning well as access for dialysis. A tunneled dialysis catheter was placed in preparation for ligation of the patient's fistula. During the procedure, the distal common iliac was exposed through a retroperitoneal approach with a longitudinal groin incision to expose the distal anastomosis site. The pseudoaneurysm was incised and oversewn. Proximal and distal anastomoses were made using the patient's arteriovenous fistula. The groin incision was closed with a sartorius muscle flap. On postoperative day (POD) 2, the patient developed a non-ST-segment elevation myocardial infarction, which was managed conservatively without further cardiac catheterization, and the patient was discharged on POD 6. On POD 16, the patient was readmitted for a groin abscess, which was treated with antibiotics and negative pressure wound therapy. No vascular or limb complications have been observed at the time of this report 2 months after the procedure. Infected pseudoaneurysms in drug abusers involving the common femoral artery have previously been treated with ligation and excision of the pseudoaneurysm with autogenous vascular reconstruction. No deaths were reported in this cohort, but patients who underwent ligation and excision only experienced significant claudication, and 33% resulted in amputation of the limb. We wished to avoid the likely complication of lower extremity amputation if our patient's pseudoaneurysm was treated with conventional methods. Prosthetic grafts would have been inappropriate with active Pseudomonas infection. Use of a mature, patent arteriovenous fistula graft as a conduit for bypass of a common femoral artery pseudoaneurysm appears to be a safe and effective option for revascularization.