Extra-anatomic lateral bypass combined with embolization of the femoral stump for management of groin infection and bleeding due to metastatic carcinoma of the penis

Interactive CardioVascular and Thoracic Surgery, May 2011

We report a possible treatment strategy for a patient with squamous cell carcinoma of the penis in hemorrhagic shock, due to erosion of the right femoral artery by metastatic inguinal lymph nodes. Because of coexistent groin infection and the inability to perform radical excision, the patient was treated with a lateral extra-anatomic iliac femoral prosthetic bypass; to prevent further bleeding, the femoral stump was embolized percutaneously. The patient was discharged home and did not experience any vascular complications during the follow-up, until death due to pulmonary metastasis.

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Extra-anatomic lateral bypass combined with embolization of the femoral stump for management of groin infection and bleeding due to metastatic carcinoma of the penis

Andrea Agostinucci 0 Nadia Sandrone 0 Claudio Baracco 0 Ferruccio Ferrero 0 0 Division of Vascular Surgery , Ospedale San Giovanni Bosco, Piazza del Donatore del Sangue 3, 10154 Turin, Italy We report a possible treatment strategy for a patient with squamous cell carcinoma of the penis in hemorrhagic shock, due to erosion of the right femoral artery by metastatic inguinal lymph nodes. Because of coexistent groin infection and the inability to perform radical excision, the patient was treated with a lateral extra-anatomic iliac femoral prosthetic bypass; to prevent further bleeding, the femoral stump was embolized percutaneously. The patient was discharged home and did not experience any vascular complications during the follow-up, until death due to pulmonary metastasis. 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. 1. Introduction Squamous cell carcinoma (SCC) is the most common tumor of the penis. It is relatively rare in Western countries, accounting for 0.40.6% of all cancers in the male population w1x. Groin lymph nodes metastasis occurs in 30% of the patients and is associated with poor prognosis w2x. Cutaneous erosion secondary to recurrence of disease or radiation therapy may result in groin infection, hemorrhagic shock due to vascular involvement, and even loss of a limb. In case of the inability to perform a radical excision, palliative treatment is based on avoiding death due to bleeding and trying to improve the patients quality of life by proceeding with limb-sparing surgery w3x. Here, we report the case of a patient with a groin infection and erosion of femoral vessels due to recurrence of SCC metastasis. Radical treatment was not possible. An extra-anatomic lateral bypass combined with percutaneous embolization of the arterial femoral stump was successful in managing bleeding and achieving adequate perfusion of the affected limb. 2. Case report A 55-year-old male with a metastatic carcinoma of the penis involving inguinal lymph nodes developed a large necrotic groin lesion on the right side that eroded the common femoral artery, causing hemorrhagic shock (Fig. 1). Three years previously the patient underwent partial penectomy for SCC. After 18 months, a lump of confluent *Corresponding author. Tel.: q39-347-8731218; fax: q39-011-2402940. E-mail address: (A. Agostinucci). 2011 Published by European Association for Cardio-Thoracic Surgery right inguinal lymph nodes was observed and a biopsy revealed SCC metastasis. A right lymphadenectomy was carried out, and the patient was subsequently treated with local radiotherapy and systemic chemotherapy. Six months following radiotherapy, an 18 fluorine-fluorodeoxyglucose (18 F-FDG) positron emission tomography (PET)-scan revealed high levels of FDG uptake in the affected groin. An additional biopsy revealed the recurrence of disease. Moreover, an iliac-femoral vein thrombosis was also detected on the affected side. Chemotherapy was discontinued due to the development of skin ulceration and infection. Due to the inability to perform a radical excision and due to the poor prognosis, the only treatment was local wound care and antibiotics. The patient was referred to our center due to hemorrhagic shock caused by massive arterial groin bleeding and an emergency operation was carried out. Proximal and distal control was obtained through a retroperitoneal approach to the external iliac artery and the superficial femoral artery at the level of the mid-thigh. A 7-mm Dacron graft was anastomosed in an end-to-side fashion to the external iliac artery, followed by distal ligation. The graft was tunneled underneath the ileopsoas fascia close to the anterior superior spine of the iliac crest, proceeding in a subcutaneous fashion. Distal anastomosis to the superficial femoral artery at the medial side of the thigh was performed in an end-to-end fashion. A subsequent computed tomography (CT) angiographic examination demonstrated functional bypass and a patent common femoral stump, as evidenced by retrograde flow from the profunda (Fig. 2). To prevent further bleeding, a percutaneous anterior mid-thigh transcatheter coil embolization was performed using the ipsilateral retrograde approach. Arterial A. Agostinucci et al. / Interactive CardioVascular and Thoracic Surgery 12 (2011) 860862 Fig. 1. Ulcerated groin lesion due to SCC metastasis. SCC, squamous cell carcinoma. access was gained via the superficial femoral artery and successful vessel occlusion was achieved with deployment of 0.0350 fibered platinum coils (Boston Scientific, Cork, Ireland) in the femoral stump. The postoperative period was uneventful and the patient was discharged after two weeks. While the patient regained good functional use of his right limb and did not experience any further bleeding, at six months after the vascular procedure, he died of pulmonary metastasis. 3. Discussion Groin metastases, particularly with involvement of femoral vasculat (...truncated)


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Andrea Agostinucci, Nadia Sandrone, Claudio Baracco, Ferruccio Ferrero. Extra-anatomic lateral bypass combined with embolization of the femoral stump for management of groin infection and bleeding due to metastatic carcinoma of the penis, Interactive CardioVascular and Thoracic Surgery, 2011, pp. 860-862, 12/5, DOI: 10.1510/icvts.2010.258434