Surgical Management Of An Infected Popliteal Artery Aneurysm And Associated Septic Knee Joint
Sitaram V. Chivukula, MD, Laurel Tangalakis, MD, Margaret Rigamer, MD, Erin Farlow, MD, Richard Keen, MD, Neha Sheng, MD.
Cook County Health and Hospital Systems, Chicago, IL, USA.
A 61 year-old male presented to the emergency department (ED) complaining of an 8 day history of left lower extremity (LLE) pain and swelling posterior to the left knee, worsened with movement. On physical exam, the patient had necrotic skin and bullae overlying the lateral aspect of the left popliteal fossa, with an associated pulsatile mass. The anterior left knee was exquisitely tender. Left pedal pulses were non-palpable but arterial Doppler signals were multiphasic. On imaging, a 3.9cm left popliteal artery aneurysm and thrombosis of the popliteal vein were identified. The patient was admitted for workup of suspected infectious etiology of the pseudoaneurysm. On hospital day 2, the patient demonstrated decreased left sensorimotor function, worsening skin changes, and had absent LLE arterial Doppler signals. He was taken emergently to the operating room for limb salvage. He underwent thrombectomy and arterial bypass graft, using contralateral saphenous vein. This was followed by four compartment fasciotomy of the left leg and resection of the infected left popliteal artery pseudoaneurysm. Intraoperatively, the orthopedic surgery team performed an arthrotomy with irrigation and debridement of the left knee, draining purulent fluid. At the end of the case, the left pedal pulses were palpable. The patient underwent serial surgical debridement of the soft tissue in the popliteal fossa, and placement of a negative-pressure wound closure device. Tissue and blood cultures were positive for Streptococcus pneumoniae. Following resolution of the infection, the patient underwent soft tissue coverage and reconstruction with a latissimus dorsi free flap.
For a necrotizing soft tissue infection with joint and vascular involvement, a multidisciplinary approach is recommended. In this case, extensive efforts were made for limb salvage. From a vascular standpoint, it is important to use an extra-anatomic reconstruction to avoid the infected field. Contralateral autologous vein is recommended as conduit to preserve ipsilateral venous outflow, and prosthetic graft should be avoided. In this case, the contralateral great saphenous vein was harvested and the bypass was tunneled subcutaneously. Interestingly, the saphenous vein was duplicated in this patient, and the duplicated vein was usable for the bypass.
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