Surgical Management Of A Large Mycotic Pseudoaneurysm Of The Distal Popliteal Artery
Kyle A. McCullough, MD, Leigh Ann O'Banion, MD, Sammy Siada, DO.
University of California San Francisco - Fresno, Fresno, CA, USA.
Surgical Management of a Large Mycotic Aneurysm of the Distal Popliteal Artery
DEMOGRAPHICSA 65 year-old male smoker with hypertension, and coronary artery disease presents with a rapidly expanding mycotic aneurysm of the below knee popliteal artery.
HISTORYThe patient presented with right calf pain, swelling and fevers following a percutaneous coronary intervention for unstable angina two weeks prior via ipsilateral groin access. Physical exam revealed a diffusely swollen, painful lower extremity. Arterial brachial indices were normal. Blood cultures grew methicillin-sensitive Staphylococcus aureus and ultrasound demonstrated a sub-centimeter distal popliteal artery aneurysm with inflammation and calf deep vein thromboses. Transesophageal echocardiography and sepsis workup revealed no etiologic source. He was discharged on IV cefazolin and eloquis with close follow-up. Due to progression of symptoms and concern for tibial nerve compression, CT angiogram was obtained showing rapid aneurysm growth to 8cm. Figure 1.
PLANThe patient underwent urgent admission and diagnostic angiography revealing a below knee popliteal artery aneurysm extending to the tibial trifurcation with three vessel runoff to the foot. He was taken to the operating room for repair of the aneurysm from a medial approach. The superficial femoral artery (SFA) was exposed for proximal control, with distal control of the anterior tibial artery (ATA) via the lateral calf, and posterior tibial artery (PTA) from a separate distal medial calf incision. Below knee popliteal exposure revealed an obliterated popliteal and tibioperoneal trunk with a large thrombosed aneurysm. The aneurysm cavity was debrided, irrigated, and a drain was placed. The distal popliteal and proximal ATA and PTA were ligated thereby excluding the aneurysm. An SFA to PTA bypass was constructed with ipsilateral reversed great saphenous vein with resulting palpable pedal pulses. . Intra-operative cultures were negative and he was discharged home after an uneventful course on IV cefazolin.
DISCUSSIONDistal peripheral arterial mycotic aneurysms present a rare and clinically challenging diagnosis. However, surgical principles of aneurysm debridement and exclusion followed by revascularization with autologous vein can lead to a successful outcome.
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