Peripheral Angioinvasive Aspergillosis in the Setting of End-Stage Liver Disease

Abstract

Invasive aspergillosis of the peripheral arteries is a rare complication in vascular surgery. Angioinvasion can compromise vascular wall integrity, leading to local and systemic complications. We report the case of peripheral angioinvasive aspergillosis of the common femoral artery (CFA) and superficial femoral artery in a patient with decompensated alcoholic liver cirrhosis. We reviewed the electronic medical records for the patient's medical history, diagnostic imaging, operative reports, and in-hospital course. All information was de-identified. A 58-year-old man with advanced alcoholic liver cirrhosis had presented to our tertiary care center for orthotopic liver transplant evaluation. A part of the workup included coronary angiography, which was performed through a 6F femoral sheath access. Subsequently, the patient developed right groin hematoma with a CFA pseudoaneurysm and evidence of femoral nerve compression. He underwent hematoma evacuation and CFA repair that required endarterectomy. His postoperative course was complicated by a recurring surgical site hematoma requiring transfusions, several groin reexplorations, and creation of a sartorius flap to provide coverage of the femoral vascular bundle. A vacuum-assisted closure device was used for wound dressing. During the ensuing days, sartorius flap necrosis developed, and the patient experienced acute arterial bleeding. On reexploration, the CFA was noted to have sieve-like bleeding with complete disintegration of the arterial wall. Ligation of the CFA, profunda femoris, and superficial femoral artery as lifesaving measures was required. The patient's condition continued to worsen, with liver failure and right leg ischemia. After the goals of care were discussed with the family, they decided for terminal extubation, after which the patient died. Evaluation of samples of the femoral vessels obtained during surgery returned positive for the presence of Aspergillus species on fungal stains within the arterial wall, with large fungal bodies protruding into the vessel segment lumen (Fig). Distorted vessel wall anatomy was also observed with dense infiltration and hyphae and evidence of vessel microperforation. The presence of invasive aspergillosis was most likely responsible for the arterial wall disintegration. Peripheral angioinvasive aspergillosis is a rare infectious complication in vascular surgery and can occur in patients with end-stage liver disease. Angioinvasion is difficult to treat and can result in vascular wall compromise, presenting as life-threatening hemorrhage.