Necrotizing Soft Tissue Infection in a Case of Femoral-Popliteal Artery Stenting—A Rare Complication

Necrotizing soft tissue infection is a rare and potentially life-threatening complication after endovascular stenting procedures. The following presents one such case of a necrotizing soft tissue infection of the femoral-popliteal artery and stent with proximal superficial femoral artery and above-knee popliteal artery by gas-producing Streptococcus anginosus. Patient information was obtained from electronic medical records at the University of Maryland Medical Center. All information was deidentified in accordance with hospital and department of vascular surgery policy and presented according to the medical education provision obtained in the surgical consent of our patients. Data and the discussion thereof are presented in compliance with the U.S. Health Insurance Portability and Accountability Act. A 77-year-old man presented to our medical center admitted from an outside medical facility with necrotizing soft tissue infection of the right groin after endovascular stent placement 9 days before admission. Stent placement was performed for the patient's complaint of claudication. On the day of admission, the patient underwent extensive débridement of skin, subcutaneous tissue, and left thigh anteromedial muscle >100 cm2 and resection of involved vascular structures, including resection of an infected femoral-popliteal artery, femoral-popliteal stent, proximal superficial femoral artery, and above-knee popliteal artery. The patient underwent subsequent return to the operating room for additional débridement on hospital days 2 and 4. On hospital day 6, he ultimately underwent a left above-knee amputation. The patient was transferred to the intensive care unit, where he received routine postoperative care including pharmacologic pressure support. Intraoperative culture specimens from his left leg were positive for S. anginosus. During his stay, he underwent an extensive infectious workup that included an echo (negative for vegetations), maxillofacial panoramic films, and computed tomography of the abdomen and pelvis that identified concern for diskitis/osteomyelitis at T11-T12. Magnetic resonance imaging confirmed concern for diskitis/osteomyelitis, resulting in a postoperative course of 6 weeks of antibiotic therapy through a right upper extremity peripherally inserted central venous catheter line. This case of necrotizing soft tissue infection represents a devastating and rare life-threatening complication of endovascular intervention in patients with significant vascular disease. Stent removal in addition to resection of grossly infected vessels and tissue and amputation represent urgent interventions that must be promptly planned and managed by skilled surgeons able to quickly identify the underlying signs and symptoms of disease.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)