A 72-year-old male patient was admitted into our centre with large infected pseudoaneurysm (PSA) in the left groin (CRP: 209.4 mg/L; WBC: 7.7 x 109/L) (Figure 1). Patient's medical history revealed the following: aortobifemoral bypass (ABR) 2006, resection of the ABF's left branch for suspected infection at a different centre 2010, and hyperlipoproteinemia. Patient's only comorbidity was compensated arterial hypertension (WHO stage 1). The patient underwent a CT angiography (CTA) that confirmed a large partly thrombosed 6.5 x 5.5 cm PSA in the left groin arising from the ABF distal anastomosis (Figure 2(a)). Furthermore, the CTA revealed 11 cm juxtarenal abdominal aortic aneurysm (JAAA) from which the proximal anastomosis of the ABF was arising (Figure 2(b)). Based on the CTA results, the patient was planned for a hybrid treatment: aorto-uni-iliac stent graft combined with femoro-femoral crossover bypass using an arterial allograft (AA). The patient was immediately started on an empiric i.v. antibiotic therapy (ATB). The patient received a daily dose of amikacin 3.6 g+ampicillin 3 g+clindamycin 1.8 g. The patient was placed on a waiting list for arterial allograft under an "urgent" status. Fresh AA (common and external iliac artery) was available within five days.
The procedure was carried out under full anaesthesia. Fist, aorto-uni-iliac stent graft Cook (Cook Ink, Bloomington, USA) was placed from the right groin with proximal landing zone below the renal arteries excluding the JAAA and the ABR. The stent graft was placed trough native severely stenotic right iliac arteries. The distal landing zone was in the common iliac artery above the iliac bifurcation maintaining patent right internal iliac artery. Afterwards, a femoro-femoral crossover bypass from right to left was performed using fresh AA. An anastomosis on the right common femoral artery was performed using polypropylene 6/0 (Figure 3(a)). The AA was subfascialy carried over to the left groin, where massive infected PSA was resected (Figure 3(b)). The proximal part of the common femoral artery was ligated below the inguinal ligament. Femoral bifurcation was dissected, and the AA was anastomosed to the femoral bifurcation using polypropylene 6/0, restoring blood flow to the superficial and deep femoral arteries (Figure 3(c)). Cultures were taken from the left groin PSA and resected left branch of the ABR.
Postprocedurally, the hospital stay was uneventful. The patient was immediately started on tacrolimus. The empiric antibiotic treatment was continued until the results of the cultures were available. The ABF left branch cultures came negative. The left groin PSA cultures came positive for Staphylococcus epidermidis and Corynebacterium tuberculostearic, both sensitive to vancomycin and rifampicin. The patient ATB treatment was changed to i.v. vancomycin for two weeks, followed by four weeks of oral rifampicin treatment.
The patient was discharged on the 20th postoperative days with patent AA bypass, low infection parameters (CRP: 27.2 mg/L; WBC: 7.7 x 109/L), tacrolimus daily dose of 9 mg (3.8 mug/L), and 100 mg daily dose of aspirin.
During the first follow-up of six weeks after discharged, the CT showed patent AA bypass and stent graft. Six months after the procedure during the second follow-up, the Doppler ultrasonography showed complete asymptomatic occlusion of AA bypass. The patient was newly diagnosed with prostate cancer. Due to asymptomatic occlusion and new oncologic diagnosis, no further action was taken in order to restore the AA bypass patency. Tacrolimus was removed from the patient's medication. Nine months after the procedure, the patient underwent high amputation of left leg complicated by wound dehiscence; non-ST-elevation myocardial infarction was treated conservatively.