We present the first case of in situ replacement of an infected subclavian artery using superficial femoral vein and the fourth reported case of an infected arterial
pseudoaneurysm caused by pseudomonas pseudomallei.
Sepsis and
hoarseness developed in a 58-year-old man after recent travel to Borneo, Indonesia. Indirect laryngoscopy revealed a paralyzed right vocal cord. Computed tomography and arteriography revealed a 6.5-cm
pseudoaneurysm of the proximal right subclavian artery. Blood cultures grew pseudomonas pseudomallei. An abnormal cardiac stress test prompted a coronary angiography, which revealed severe
coronary artery disease.The patient underwent
coronary artery bypass and in situ replacement of the infected subclavian artery
pseudoaneurysm with a superficial femoral vein, along with placement of a pectoralis major muscle flap to cover the vein graft. Operative cultures of the
pseudoaneurysm grew pseudomonas pseudomallei. The patient was treated with a 6-week course of intravenous
ceftazidime and oral
doxycycline and then continued on oral
amoxicillin-
clavulanate. One week after discontinuing intravenous
antibiotics, the patient presented to the emergency department with a rapidly expanding, pulsatile mass in the right supraclavicular space. He was taken emergently to the operating room. After hypothermic circulatory arrest was accomplished, the disrupted vein graft and
aneurysm cavity were resected and the subclavian artery was oversewn proximally and distally. Parenteral
ceftazidime was continued for 3 months and oral
amoxicillin-
clavulanate (
augmentin) was continued indefinitely. There was no evidence of
infection clinically or by computed tomographic scan 2 years later. Although autogenous vein replacement of infected arteries and grafts may be successful in the majority of cases, this strategy should probably be avoided when particularly virulent bacteria such as the organism in this case are present.