Clinical Scorecard: An Uncommon Instance of Mycotic Pseudoaneurysm in the Common Femoral Artery Due to Septic Ankle Arthritis: Considerations for Surgical and Endovascular Approaches

At a Glance

Key Highlights

• Mycotic aneurysms are rare (<1% of aneurysms) but carry high morbidity including rupture, sepsis, and limb loss.
• In situ reconstruction with autologous vein grafts is preferred over extra-anatomic bypass due to better infection resistance and patency.
• Endovascular techniques can be adjunctive but require careful infection control and preservation of surgical graft integrity.

Guideline-Based Recommendations

Diagnosis

• Use computed tomographic angiography (CTA) to identify pseudoaneurysm size and extent.
• Obtain blood cultures and site-specific cultures to identify causative pathogens.
• Employ imaging (MRI, radiographs) to assess source of infection such as osteomyelitis or septic arthritis.

Management

• Initiate broad-spectrum intravenous antibiotics targeting common pathogens including MRSA.
• Perform surgical excision and extensive debridement of infected arterial segments.
• Use autologous reversed femoral vein grafts for in situ arterial reconstruction.
• Apply rotational muscle flaps and negative pressure wound therapy for soft tissue coverage and infection control.
• Coordinate multidisciplinary care including orthopedic debridement of infected joints.
• Consider staged endovascular revascularization after infection control to address distal occlusions.

Monitoring & Follow-up

• Monitor inflammatory markers (ESR, CRP) and leukocyte counts to assess infection control.
• Perform serial imaging to evaluate graft patency and resolution of infection.
• Assess clinical signs of limb perfusion and wound healing postoperatively.

Risks

• Risk of graft reinfection if infection control is inadequate.
• Potential for rupture or limb ischemia if pseudoaneurysm is untreated.
• Iatrogenic injury during endovascular intervention near fresh surgical anastomoses.

Patient & Prescribing Data

Elderly patients with comorbidities including diabetes, chronic kidney disease, and vascular disease presenting with infected pseudoaneurysms

Targeted intravenous antibiotics (e.g., vancomycin and piperacillin-tazobactam) are essential alongside surgical and endovascular interventions; early multidisciplinary involvement improves outcomes.

Clinical Best Practices

• Early multidisciplinary collaboration among vascular surgery, orthopedics, and infectious disease teams.
• Use of autologous vein grafts for arterial reconstruction in infected fields to reduce reinfection risk.
• Careful planning of endovascular access to avoid disruption of fresh surgical grafts and anastomoses.
• Employ negative pressure wound therapy and muscle flap coverage to optimize soft tissue healing.
• Staged approach with initial infection control followed by endovascular revascularization for distal occlusions.

References

• 1. General epidemiology and management of mycotic aneurysms
• 2. Common pathogens in mycotic aneurysms
• 3-5. Evidence supporting autologous vein grafts for in situ reconstruction
• 5-6. Role of endovascular techniques in mycotic aneurysm management