Syndactylization as a technique in treatment of infectious limb following aortobifemoral reconstruction

The incidence of prosthetic vascular graft infection is estimated at 0.5–6%. ¹ The complication is a major burden to vascular surgeons and their patients, with significant time and cost implications. Management can be difficult and the outcome is often disappointing. We present the case of the patient with infectious limb following aortobifemoral reconstruction treated by partial graft extirpation and with re-implantation of the superficial femoral artery into deep femoral artery.

Patient aged 58 was admitted in our hospital with signs of the pulsatile mass with putrid secernation in the left groin. Seven years ago he underwent aortobifemoral reconstruction due to chronic abdominal aortic occlusion. Following three years without symptoms he was treated as an emergency case after acute left limb occlusion. Thrombectomy, elongation of the left limb in the proximal part of the deep femoral artery and re-implantation of the superficial femoral artery was performed. The wound healed without complications and the patient was discharged routinely. Last year he was admitted in our hospital again, now with infectious left limb of previously placed aortobifemoral graft. On admission he had palpable pedal pulses. Translumbar aortography showed good distal run of with patent limb, superfitial, deep femoral artery and huge pseudoaneurysm formation in the left groin. Computed tomography scan of the abdomen excluded infectious process in the abdomen and around the body of aortobifemoral graft. We have decided to do partial limb extirpation through femoral incision and re-implantation of the superfitial femoral artery into deep femoral artery using termino-terminal anastomosis (Figure 1). Tissue and graft samples taken intraoperatively revealed infection caused by Pseudomonas aeruginosa. Postoperative course was uneventful. Patient was discharged on day 7 in good condition with claudications above 100 m. Follow up after six months revealed unchanged condition, claudications above 100 m and confirmed patent reconstruction on the control angiography (Figure 2). OPEN IN VIEWER

Figure 1

Intraoperative view. Superfitial femoral artery under ‘bulldog’. Deep femoral artery hooked by yellow tape

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Figure 2

Control angiography showing anastomosis between superfitial and deep femoral artery (black arrow)

Prosthetic graft infection is an uncommon complication after vascular graft surgery that varies from low-grade infections with a low-morbidity and -mortality rate to fulminant, acute, live treating infections with a high morbidity and mortality rate. ² Surgical treatment of an infected aortic graft focuses on treatment of the infection and maintaining or restoring perfusion of the lower limbs. Traditionally, this is done by removing the graft, extensive debridement, constructing an extra-anatomic bypass, usually an axillobifemoral bypass (AXBF) as well as using of NAIS (neo-aorto iliac system). The disappointing early results of these reconstructions prompted various surgeons to develop new surgical treatment options to secure lower limb perfusion. ³ ‘Syndactylization’ was previously described as a technique in reconstruction of femoral aneurysms by suturing of superfitial and deep femoral arteries together to form a common lumen followed by graft interposition. Our decision to perform ‘syndactylization’ technique was made on basis of good collateral circulation in patients with chronic aortic occlusion, especially through network between hypogastric and deep femoral arteries and because of impossibility of an extra-anatomic bypass reconstruction in this particular patient. The reason to maintain the continuity between deep femoral and superfitial femoral artery was made by the fact that the patent superfitial femoral artery usually has poorly developed collateral network between deep femoral and above the knee popliteal artery. So, the ligature was not an option. Furthermore, we have hypothesized that this collateral network with patent superfitial femoral artery would be sufficient to maintain a minimum amount of circulation for the leg. Good run of in that group of patients is usually a consequence of protective effect of chronic aortic occlusion on the progression of distal arterial disease. ⁴

We believe that this technique could be of benefit for particular group of patients, who were operated on due to chronic aortic occlusion followed by limb infection. Prerequisite for this technique is patent distal arterial three. This technique could serve as a bridge solution for definite subsequent AXBF after infection eradication.

In conclusion this simple technique can provide a big relief to every vascular surgeon and patient who has experienced this dreadful complication.