Tim Trstenjak1, Nikola Lakič2, Mark Racman3, Tadeja Kolar4
Surgical Treatment of Endarteritis in the
Iliofemoral Region with the Use of Selective
Left Lower Limb Perfusion During a Prolonged
Vascular Reconstruction – A Case Report
ABSTRACT
KEY WORDS: septic endarteritis, selective distal perfusion, Staphylococcus aureus, homograft
Surgical treatment of septic endarteritis of the iliofemoral region can result in prolonged
ischemia of the lower extremities. Distal perfusion of the limb can improve early post-
operative outcomes. We present a case of a 35-year-old woman who was diagnosed with
septic endarteritis of the right iliofemoral region as a consequence of residual wire frag-
ments from a prior endovascular procedure. During the intervention, the entire right
iliofemoral arterial segment was replaced with a homograft due to the destruction of native
arterial walls. Because of the extent of the replacement and predicted duration of the pro-
cedure, we used selective distal perfusion of her right leg to minimize the possibility of
ischemia and reperfusion injury to the tissues, which is usually followed by compart-
ment syndrome. The patient recovered fully. This case highlights the importance of a multi-
disciplinary approach when it comes to the treatment of rare and complex cases. 
1 Tim Trstenjak, dr. med., Klinični oddelek za kardiovaskularno kirurgijo, Univerzitetni klinični center Ljubljana,
Zaloška cesta 7, 1000 Ljubljana
2 Dr. Nikola Lakič, dr. med., svetnik, Klinični oddelek za kardiovaskularno kirurgijo, Univerzitetni klinični center
Ljubljana, Zaloška cesta 7, 1000 Ljubljana
3 Mark Racman, dr. med., Klinični oddelek za kardiovaskularno kirurgijo, Univerzitetni klinični center Ljubljana,
Zaloška cesta 7, 1000 Ljubljana
4 Asist. dr. Tadeja Kolar, dr. med.,Klinični oddelek za kardiovaskularno kirurgijo, Univerzitetni klinični center Ljubljana,
Zaloška cesta 7, 1000 Ljubljana; tadeja.kolar@kclj.si
15Med Razgl. 2024; 63 Suppl 2: 15–19 • doi: 10.61300/angc33
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INTRODUCTION
Septic endarteritis following endovascular
procedures is a rare complication, report-
ed in less than 1% of patients. Presentation
within one to two weeks after the procedure
is most common. Sites of infection usually
include the groin region with inflamed
skin, endarteritis, and/or pseudoaneurysm
formation. Intravenous antibiotic treat-
ment is considered the first line of treat-
ment, but most patients require some sort
of surgical intervention (1). In case of exten-
sive arterial wall destruction, it is necessary
to surgically replace the entire vessel seg-
ment. A reperfusion injury after such a pro-
cedure is a very common complication. Using
selective perfusion of the affected limb
could minimize the reperfusion injury to the
limb and kidneys following the procedure.
Written informed consent was obtained
from the patient for publication of this case
report and accompanying images.
CASE REPORT
A 35-year-old female with a history of
endovascular procedures presented with
a fever, headache, vomiting, pain in her
right leg, and Osler’s nodes (onset of symp-
toms two days prior to hospitalization).
Inflammatory markers were elevated. An
empirical intravenous antibiotic treatment
was started (flucloxacillin, ceftriaxone).
Haemocultures and the fluid from arthro-
centesis of the right knee were later posi-
tive for Staphylococcus aureus, so antibiotic
treatment was readjusted (flucloxacillin
only). An echocardiography displayed no
evidence of endocarditis. An X-ray and a CT
scan showed foreign material (residual
wire) present in the right iliac and femoral
arteries with thrombosis in the right com-
mon femoral artery from prior endovascu-
lar procedures (from 2006 and 2012).
A positron emission tomography com-
bined with a CT (PET-CT) scan showed sig-
nificantly elevated metabolic activity along
the iliac arteries, common femoral artery
(CFA), and superficial femoral artery (SFA)
indicating possible inflammation in this
region.
After two weeks of conservative med-
ical treatment, the patient underwent an
endovascular procedure to extract the resi-
dual material. The attempt was unsuccess-
ful due to wire adhesion to the arterial wall.
Five days later, the patient was operated on
again, this time with an open surgical tech-
nique to remove foreign material and replace
the extensive vessel segment, severely
affected by endarteritis. Following proximal
and distal exposure of the vessels, common
iliac artery was clamped proximally and
SFA distally. We perfused the distal part of
the right leg via arterial cannulas (size 8 Fr)
inserted in the distal SFA and femoral vein
with a venous cannula (size 10 Fr) (figure 1).
We used a roller pump and a children’s oxy-
genator (Dideco Kids D101). The priming
fluid was Ringer’s lactate with a 50 mg
dose of heparin. The limb was supported
with a flow of 50–130 mL/min (average:
86.00±0.35mL/min). Arterial line pressure was
59–70mmHg (average: 60.60±6.58mmHg).
Hematocrit values during selective perfu-
sion from the oxygenator were between
23.6–26.8% (average: 25.12 ± 1.44%) and
activated clotting time (ACT) was 361–564s
(average: 446.33 ± 105.29 s). Then the rest
of the vessels were exposed, the wire and
the affected arteries were removed, and the
segment was replaced with two homo-
grafts. Selective perfusion of the leg was
discontinued after 73 minutes by removing
the clamps. Before closing, the wound was
thoroughly rinsed.
After the surgery, the patient was pre-
scribed lifelong acetylsalicylic acid and
antibiotics for four weeks. Creatinine and
myoglobin were only slightly elevated
immediately after the procedure (probably
due to ischemia of the thigh and buttock) and
returned to normal values the same day. The
patient gained full function of her lower limb
during hospitalization. 
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The patient was discharged from hos-
pital after seven weeks. On the six-month
follow-up appointment, the patient denied
any problems concerning the functionali-
ty of her right leg or any signs of inflam-
mation.
DISCUSSION
To our knowledge, this is the first case of
peripheral vascular reconstructive surgery
to treat septic endarteritis, where selective
perfusion of a limb during the procedure
was used to minimize ischemia and reper-
fusion injury due to predicted longer dura-
tion of intraoperative limb ischemia.
17Med Razgl. 2024; 63 Suppl 2:
Caudal
Cranial
Venous cannula
Arterial cannula
Figure 1. Cannulation of the superficial femoral artery and femoral vein, and selective perfusion.
Angioloski 2024_Mr10_2.qxd  19.9.2024  8:46  Page 17
Ischemic injury is responsible for cel-
lular death and also for cellular edema,
which can further compromise tissue per-
fusion (2). The reperfusion of ischemic tis-
sues leads to the release of bioproducts
of muscle ischemia and cell necrosis into
circulation (potassium, phosphate, organic
acids, myoglobin, creatine kinase, and
thromboplastin), and can cause systemic
complications such as cardiac depression,
acute lung injury, renal failure and poorer
limb-related functional outcomes (3). A study
by Perkins and colleagues on the impact of
ischemia duration on lower limb salvage in
combat casualties showed that the thresh-
old to restitution of blood flow should be
much less than the ubiquitous six hours –
the probability of limb salvage was still
only around 60% when ischemia was < 3
hours (4). Current therapies aimed at mit-
igating ischemia-reperfusion injury are
mostly just supportive, by providing ade-
quate hydration, electrolyte correction,
vasopressor support, and acid-base man-
agement only after reperfusion has occurred. 
A controlled reperfusion of the lower
extremity was shown to improve outcome
after acute severe lower-limb ischemia by
using a crystalloid reperfusion solution
with glucose, tromethamine glutamate,
aspartate, allopurinol, and sodium citrate (5).
During elective major vascular operations,
ischemic postconditioning proved to be
capable of conferring protection against
different organ injuries caused by longer
circulatory occlusions (6). Several studies
suggest that selective renal and visceral
perfusion during thoracoabdominal aortic
aneurysm repair improves outcomes (7).
In our case, selective distal perfusion in
a peripheral vascular surgery offers a solu-
tion through which malperfusion of a limb
can be completely avoided during an oper-
ation, thereby, avoiding the possibility of
reperfusion injury. It is particularly suitable
for major reconstructive vascular surgery,
where the procedure itself is the cause of
temporary acute ischemia.
CONCLUSIONS
The use of distal perfusion of the limb dur-
ing a reconstructive vascular procedure
highlights the importance of interdisci-
plinary involvement in the improvement of
patient outcomes, especially in those with
anticipated prolonged limb ischemia due to
a surgical procedure.
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