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Trash buttock: An unusual complication of aortic surgery
Eur J Vasc Surg 5, 215-216 (1991)
CASE REPORT
Trash Buttock: An Unusual Complication of Aortic Surgery S. C. Hardy, P. Vowden and M. J. Gough* Vascular Surgical Unit, Bradford Royal Infirmary, Bradford BD9 6RJ, U.K. A case of buttock and thigh necrosis following an aorto-bifemoral graft is reported. This unusual complication is the result of microembolisation of the internal Jliac artery.
Introduction Patchy ischaemia of the toes following abdominal aortic surgery is a well recognised complication.~ It is thought to be the result of microembolisation of atheromatous debris from the proximal vessels. We report here a patient who developed skin necrosis of the buttock and thigh following an aorto-bifemoral graft and would suggest that it was the result of microembolisation of the internal iliac artery, a hitherto unrecognised complication of such surgery.
tion there was marked patchy ischaemia of the left thigh and buttock. In view of the previous arteriographic findings a left below knee femoro-popliteal bypass was undertaken some 8 h following the initial surgery. At operation there was good forward flow in the left limb of the Y graft and no thrombus or debris could be retrieved from the left profunda femoris artery. Following the femoro-popliteal bypass there was satisfactory restoration of the distal pulses at the left ankle. However the ischaemia of the buttock and thigh progressed to patchy skin necrosis (Fig. 1). At 3-month follow-up the patient's blood pressure and
Case Report A 54-year-old w o m a n presented with severe bilateral lower limb claudication, together with uncontrolled hypertension and mild renal impairment (creatinine 230mmol/1). Arteriography indicated bilateral renal artery stenosis with virtual occlusion of the left renal artery, diffuse aortic narrowing and bilateral superficial femoral occlusions. A knitted dacron aorto-bifemoral graft was performed with bilateral profundoplasties. Endto-side anastomoses were fashioned both proximally and distally. In addition the left renal artery was revascularised with a saphenous vein jump graft. Postoperatively there was satisfactory revascularisation of the right limb. The left leg however remained cold with a sluggish capillary circulation in the toes. In addi*To whom all correspondenceshould be sent. 0950-821X/91/020215+02 $03.00/0 © 1991 Grune & Stratton Ltd.
Fig. 1. Photograph of patient's patchy skin necrosis.
216
S . C . Hardy e t al.
r e n a l function are n o r m a l a n d the ischaemic a r e a s previously described h a v e healed.
Discussion F o l l o w i n g h e r initial s u r g e r y this p a t i e n t ' s limb b e c a m e critically i s c h a e m i c despite a p a t e n t profundoplasty. The s u b s e q u e n t femoro-popliteal graft restored the c i r c u l a t i o n to the left leg but t h e i s c h a e m i a of the b u t t o c k a n d thigh r e m a i n e d , u l t i m a t e l y progressing to p a t c h y necrosis. It is suggested t h a t these p r o b l e m s arose as a result of microe m b o l i s a t i o n of the left i n t e r n a l iliac a r t e r y a n d p r o f u n d a femoris artery. Occlusion of the gluteal vessels resulted n o t only in the i s c h a e m i c c h a n g e s of the b u t t o c k a n d t h i g h b u t also c a u s e d a significant r e d u c t i o n in the collateral supply to the left leg. M i c r o e m b o l i s a t i o n of m a j o r vessels c a n o c c u r either de novo (Blue Toe S y n d r o m e ) 2 or following s u r g e r y (Trash Foot). 1 Morphologically these emboli consist of cholesterol crystals, 3 platelet aggregates, or fibrin t h r o m b i , 4 m e a s u r i n g 1 0 0 - 2 0 0 ~ t m . ~ Characteristieally s u c h m i c r o e m b o l i s a t i o n leads to p a t c h y skin necrosis, l, s A single previous case of embolisation of the i n t e r n a l iliac a r t e r y h a s been r e p o r t e d w h i c h resulted in r u p t u r e of the bladder. 6 T r e a t m e n t of this surgical c o m p l i c a t i o n is difficult. Theoretically the use of a n t i c o a g u l a n t s m a y p r e v e n t dis-
Eur J Vasc Surg Vol 5, April 1991
tal p r o p a g a t i o n of the t h r o m b u s a n d t h u s progression of t h e i s c h a e m i c changes. H o w e v e r a n t i c o a g u l a n t s p r e v e n t t h e f o r m a t i o n of a stable t h r o m b u s t h u s predisposing to f u r t h e r emboli. 4 For m o s t patients therefore the only active t r e a t m e n t t h a t m a y be a p p r o p r i a t e is s u b s e q u e n t a m p u t a t i o n or surgical d e b r i d e m e n t of t h e necrotic tissue. A l u m b a r s y m p a t h e c t o m y h o w e v e r m a y e n h a n c e t h e h e a l i n g of p e r s i s t e n t i s c h a e m i c ulceration.5
References 1 KESTERRC, LEVESONSH. A Practice of Vascular Surgery. London: Pitman Books Limited, 1981. 2 FISHERDF JR, CLAGETTGP, BRIGHAMRA, ORECCHIAPM, YOUK~YJR, ARONOTFRJ, FRY WJ. Dilemmas in dealing with the blue toe syndrome aortic versus peripheral source. Am J Surg 1984; 148: 836839. 3 FLINNWR, HARRISJP, RUDOMD, BERGANJJ, YAOJST. Atheroembolism as a cause of graft failure in femero-distal reconstruction. Surgery 1981; 90: 698-705. 4 BRENOWITZJB, EDWARDSWS. The management of atheromatous emboli to the lower extremities. Surg Gynaecol Obstet 1976; 143: 941-945. 5 KEMPCZINSKIRE. Lower extremity arterial emboli from ulcerating atherosclerotic plaques. J Am Med Assoc 1979; 241: 807-810. 6 PISERIA, KAMERM, ROWLANDRG. Spontaneous bladder rupture owing to atherosclerotic emboli a case report. J Urol 1986; 136: 1068-1070. Accepted 31 March 1989
CASE REPORT
Trash Buttock: An Unusual Complication of Aortic Surgery S. C. Hardy, P. Vowden and M. J. Gough* Vascular Surgical Unit, Bradford Royal Infirmary, Bradford BD9 6RJ, U.K. A case of buttock and thigh necrosis following an aorto-bifemoral graft is reported. This unusual complication is the result of microembolisation of the internal Jliac artery.
Introduction Patchy ischaemia of the toes following abdominal aortic surgery is a well recognised complication.~ It is thought to be the result of microembolisation of atheromatous debris from the proximal vessels. We report here a patient who developed skin necrosis of the buttock and thigh following an aorto-bifemoral graft and would suggest that it was the result of microembolisation of the internal iliac artery, a hitherto unrecognised complication of such surgery.
tion there was marked patchy ischaemia of the left thigh and buttock. In view of the previous arteriographic findings a left below knee femoro-popliteal bypass was undertaken some 8 h following the initial surgery. At operation there was good forward flow in the left limb of the Y graft and no thrombus or debris could be retrieved from the left profunda femoris artery. Following the femoro-popliteal bypass there was satisfactory restoration of the distal pulses at the left ankle. However the ischaemia of the buttock and thigh progressed to patchy skin necrosis (Fig. 1). At 3-month follow-up the patient's blood pressure and
Case Report A 54-year-old w o m a n presented with severe bilateral lower limb claudication, together with uncontrolled hypertension and mild renal impairment (creatinine 230mmol/1). Arteriography indicated bilateral renal artery stenosis with virtual occlusion of the left renal artery, diffuse aortic narrowing and bilateral superficial femoral occlusions. A knitted dacron aorto-bifemoral graft was performed with bilateral profundoplasties. Endto-side anastomoses were fashioned both proximally and distally. In addition the left renal artery was revascularised with a saphenous vein jump graft. Postoperatively there was satisfactory revascularisation of the right limb. The left leg however remained cold with a sluggish capillary circulation in the toes. In addi*To whom all correspondenceshould be sent. 0950-821X/91/020215+02 $03.00/0 © 1991 Grune & Stratton Ltd.
Fig. 1. Photograph of patient's patchy skin necrosis.
216
S . C . Hardy e t al.
r e n a l function are n o r m a l a n d the ischaemic a r e a s previously described h a v e healed.
Discussion F o l l o w i n g h e r initial s u r g e r y this p a t i e n t ' s limb b e c a m e critically i s c h a e m i c despite a p a t e n t profundoplasty. The s u b s e q u e n t femoro-popliteal graft restored the c i r c u l a t i o n to the left leg but t h e i s c h a e m i a of the b u t t o c k a n d thigh r e m a i n e d , u l t i m a t e l y progressing to p a t c h y necrosis. It is suggested t h a t these p r o b l e m s arose as a result of microe m b o l i s a t i o n of the left i n t e r n a l iliac a r t e r y a n d p r o f u n d a femoris artery. Occlusion of the gluteal vessels resulted n o t only in the i s c h a e m i c c h a n g e s of the b u t t o c k a n d t h i g h b u t also c a u s e d a significant r e d u c t i o n in the collateral supply to the left leg. M i c r o e m b o l i s a t i o n of m a j o r vessels c a n o c c u r either de novo (Blue Toe S y n d r o m e ) 2 or following s u r g e r y (Trash Foot). 1 Morphologically these emboli consist of cholesterol crystals, 3 platelet aggregates, or fibrin t h r o m b i , 4 m e a s u r i n g 1 0 0 - 2 0 0 ~ t m . ~ Characteristieally s u c h m i c r o e m b o l i s a t i o n leads to p a t c h y skin necrosis, l, s A single previous case of embolisation of the i n t e r n a l iliac a r t e r y h a s been r e p o r t e d w h i c h resulted in r u p t u r e of the bladder. 6 T r e a t m e n t of this surgical c o m p l i c a t i o n is difficult. Theoretically the use of a n t i c o a g u l a n t s m a y p r e v e n t dis-
Eur J Vasc Surg Vol 5, April 1991
tal p r o p a g a t i o n of the t h r o m b u s a n d t h u s progression of t h e i s c h a e m i c changes. H o w e v e r a n t i c o a g u l a n t s p r e v e n t t h e f o r m a t i o n of a stable t h r o m b u s t h u s predisposing to f u r t h e r emboli. 4 For m o s t patients therefore the only active t r e a t m e n t t h a t m a y be a p p r o p r i a t e is s u b s e q u e n t a m p u t a t i o n or surgical d e b r i d e m e n t of t h e necrotic tissue. A l u m b a r s y m p a t h e c t o m y h o w e v e r m a y e n h a n c e t h e h e a l i n g of p e r s i s t e n t i s c h a e m i c ulceration.5
References 1 KESTERRC, LEVESONSH. A Practice of Vascular Surgery. London: Pitman Books Limited, 1981. 2 FISHERDF JR, CLAGETTGP, BRIGHAMRA, ORECCHIAPM, YOUK~YJR, ARONOTFRJ, FRY WJ. Dilemmas in dealing with the blue toe syndrome aortic versus peripheral source. Am J Surg 1984; 148: 836839. 3 FLINNWR, HARRISJP, RUDOMD, BERGANJJ, YAOJST. Atheroembolism as a cause of graft failure in femero-distal reconstruction. Surgery 1981; 90: 698-705. 4 BRENOWITZJB, EDWARDSWS. The management of atheromatous emboli to the lower extremities. Surg Gynaecol Obstet 1976; 143: 941-945. 5 KEMPCZINSKIRE. Lower extremity arterial emboli from ulcerating atherosclerotic plaques. J Am Med Assoc 1979; 241: 807-810. 6 PISERIA, KAMERM, ROWLANDRG. Spontaneous bladder rupture owing to atherosclerotic emboli a case report. J Urol 1986; 136: 1068-1070. Accepted 31 March 1989