Necrotizing fasciitis following saphenofemoral junction ligation with long saphenous vein stripping: a case report

Abstract

IntroductionNecrotizing fasciitis is a rare condition with a mortality rate of around 34%. It can be mono- or polymicrobial in origin. Monomicrobial infections are usually due to group A streptococcus and their incidence is on the rise. They normally occur in healthy individuals with a history of trauma, surgery or intravenous drug use. Post-operative necrotizing fasciitis is rare but accounts for 9 to 28% of all necrotizing fasciitis. The incidence of wound infection following saphenofemoral junction ligation and vein stripping is said to be less than 3%, although this complication is probably under-reported. We describe a case of group A streptococcus necrotizing fasciitis following saphenofemoral junction ligation and vein stripping.Case PresentationA 39-year-old woman presented three days following a left sided saphenofemoral junction ligation with long saphenous vein stripping at another institution. She had a three day history of fever, rigors and swelling of the left leg. She was pyrexial and shocked. She had a very tender, swollen left groin and thigh, with a small blister anteriorly and was in acute renal failure. She was prescribed intravenous penicillin and diagnosed with necrotizing fasciitis. She underwent extensive debridement of her left thigh and was commenced on clindamycin and imipenem. Post-operatively, she required ventilatory and inotropic support with continuous veno-venous haemofiltration. An examination 12 hours after surgery showed no requirement for further debridement. A group A streptococcus, sensitive to penicillin, was isolated from the debrided tissue. A vacuum assisted closure device was fitted to the clean thigh wound on day four and split-skin-grafting was performed on day eight. On day 13, a wound inspection revealed that more than 90% of the graft had taken. Antibiotics were stopped on day 20 and she was discharged on day 22.ConclusionNecrotizing fasciitis is a very serious complication for a relatively minor, elective procedure. To the best of our knowledge, this is the first report in the English-language literature of this complication arising from a standard saphenofemoral junction ligation and vein stripping. It highlights the need to be circumspect when offering patients surgery for non-life-threatening conditions.

Patient injuries in the treatment of superficial venous insufficiency registered in Finland between 2004 and 2017

“…Varicose vein surgery is not a high risk surgery for necrotizing fasciitis and with the increase of endovenous SVI operations they are likely to become exceedingly rare. 26 No infection injuries involving endovenous techniques were compensated in our dataset.…”

Necrotising Fasciitis: Appearances Can Be Deceptive

“…2,3 The major risk factors are diabetes, peripheral vascular disease, old age and immune-compromised status but can primarily affect healthy individual too. 4 Surgical procedures, post-cesarean section and minor wounds are usual pre-disposing factors. The extremities, abdominal wall and perineum are more commonly affected than other regions.…”

“… 2 , 3 The major risk factors are diabetes, peripheral vascular disease, old age and immune-compromised status but can primarily affect healthy individual too. 4 …”

Nicolau's Syndrome Complicated by Atypical Necrotizing Fasciitis

“…The latter is an uncommon and rapidly spreading infection involving the superficial fascial plane and subcutaneous tissue with a high risk of systemic toxicity and complications like adult-respiratory distress syndrome, acute renal failure, cardiac failure, or even multi-organ failure. Risks factors include immunosuppression, diabetes, age older than 50 years, malnutrition, and peripheral vascular disease [ 5 ]. The mortality rate is around 34%, and it is classified into two types: type 1, which accounts for about two thirds of the cases, is polymicrobial and mainly occurs in association with significant co-morbidities, while type 2 is caused by group A Streptococcus mainly in patients with a history of trauma, intravenous drug abuse, or surgery [ 4 ].…”