Management of Popliteal Artery Interposition Graft Infection by Extra-anatomic Bypass

Objectives: Infection of peripheral interposition grafts is a rare but devastating complication following aneurysm repair. Typically, graft infection necessitates explantation and, if possible, revascularization of the limb. However, treatment complexity varies substantially depending on the location and extent of infection. This case describes the management of a popliteal artery interposition graft infection. Methods: We describe an 84 year old male with a history of left popliteal artery aneurysm repair with PTFE interposition graft (found on workup a year prior for a gangrenous great toe) who presented with four days of night sweats, chills, and a painful posterior left knee. Laboratory findings indicated leukocytosis, while ultrasound and CT imaging revealed complex fluid surrounding the graft without evidence of pseudo-aneurysm. Surgical management was conducted in two stages, the first with the patient supine for bypass from the superficial femoral artery to the posterior tibial artery using ipsilateral reversed great saphenous vein. The patient was then repositioned prone for the second stage of the procedure, and the infected popliteal fossa was entered posteriorly for debridement with caution to avoid injury to the tibial nerve and popliteal vein. The infected graft was removed, and antibiotic beads were placed in the infected region. Results: Following this procedure and serial washouts one week later, the patient retained motor function, sensation, and palpable posterior tibial and dorsal pedal pulses. The patient was placed on IV cefazolin for 6 weeks following the procedure and discharged with 6 months of oral suppression to achieve long-term prevention of further infection. Conclusions: When managing popliteal artery graft infection, the presence of purulent material in the popliteal fossa can make anatomic bypasses high-risk for recurrent infection, and caution must be taken to avoid the nearby popliteal vein and tibial nerve during irrigation and debridement.