Case report
1990, The British Journal of Radiology, 63, 224-226 balloon aortic valvuloplasty with transoesophageal echocardiography. American Heart Journal, 115, 460-462. FOWLES, R. E. & MASON, J. W., 1984. Role of cardiac biopsy in the diagnosis and management of cardiac disease. Progress in Cardiovascular Diseases, 27, 153-172. NELLESSEN, U., DANIEL, W. G. & LICHTLEN, P. R., 1986.
The
diagnostic value of transoesophageal echocardiography in the detection of cardiac and extracardiac masses. Zeitschrift fur Kardiologie, 75, 91-98. NEUMANN, H. P. H., HOFMANN, T., KOESTER, W., BILLMANN, P.
& KAUFFMANN, G. W., 1988. Extraction of an intracardiac catheter embolus using combined radiography and transoesophageal echocardiography. Clinical Cardiology, 11, 427-429. DI
PENNESTRI, F., LOPERFIDO, F., SALVATORI, M. P., MONGIARDO, R., MAZZARI, M., MONTENERO, A. S. &
COPPOLA, E., 1982. L'eco 2D nella guida all'esecuzione della biopsia miocardica. Cardiologia, 27, 1141-1145. ROELANDT,
J.
R.
I.
C.
&
SUTHERLAND,
G.
R.,
1988.
Oesophageal echocardiography. (Editorial) British Heart Journal, 60, 1-3. SCHLUTER, M . , LANGENSTEIN, B. A., POLSTER, J., KREMER, P., SOUQUET, J., ENGEL, S. & HANRATH, P., 1982.
Transoesophageal cross-sectional echocardiography with a phased array transducer system. Technique and initial clinical results. British Heart Journal, 48, 67-72. SEKIGUCHI, M. & TAKE, M., 1980. World survey of catheter biopsy of the heart. In Cardiomyopathy: Clinical, Pathological and Theoretical Aspects, ed. by M. Sekiguchi and M. Take (University Park Press, Baltimore and University of Tokyo Press, Tokyo), pp. 217-225.
Iliopsoas abscess: an unusual complication of femoral artery catheterization By E. J. Loveday, MRCP, K. A. Tonge, FRCR and *H. G. du Peloux Menage, BSc, MRCP Departments of Radiology and 'Neurology, St Thomas' Hospital, London SE1 7EH (Received July 1989)
We report a case of iliopsoas abscess following percutaneous transfemoral carotid angiography. To our knowledge there are no previous reports of this complication. Case report The patient, a woman aged 49, was admitted for investigation of occlusive cerebrovascular disease. She was a smoker and had a history of exopthalmic Graves' disease and thyrotoxicosis, previously treated with Iodine 131. Current medications were thyroxine, Voltarol Retard and Nifedipine Retard. Prior to the procedure, haemoglobin level was 14.2 g/dl, white cell count was 8400 x 103/ml and platelet count was 283 000 x 103/ml. Full clotting studies were normal. Carotid arteriography was performed using a modified Seldinger technique. Full aseptic precautions were taken including groin shave, cleansing with chlorhexidine, povidone iodine skin preparation and sterile drapes and gowns. A 5 F Mani catheter (William Cook Europe ApS) and a 0.035 inch straight guidewire were used during the procedure which was protracted owing to inability to catheterize the left common carotid artery. A subsequent arteriogram using a 5 F pigtail catheter revealed complete occlusion of this vessel at its origin. Compression was applied to the puncture site for 20 min. The patient was well following the procedure and was discharged home shortly thereafter. Minor bruising only was seen at the puncture site. She presented again 22 days post-investigation complaining of increasing pain in the right groin and difficulty with walking. On examination she was pyrexial; and greenish, offensive Address correspondence to Dr E. J. Loveday, Department of Radiology, St. Thomas' Hospital, Lambeth Palace Road, London SE1 7EH.
224
smelling fluid was oozing from the puncture site in the right groin. There was a 30° fixed flexion deformity of the right hip, and any attempt to straighten the leg resulted in severe pain. Haemoglobin concentration had fallen to 10.5 g/dl and the white cell count had risen to 21 000 x 103/ml. A computed tomographic (CT) scan of the abdomen and pelvis was performed, and this confirmed the clinical diagnosis of a retroperitoneal abscess involving the iliopsoas muscles, with extension down into the groin, posterior to the femoral vessels (Fig. 1). An intravenous digital subtraction angiography examination showed no abnormality of the iliac or femoral arteries and no impairment of the arterial supply to the legs. Wound swabs from the puncture site grew Staphylococcus aureus. At operation a large loculated retroperitoneal abscess was found and this was subsequently drained. Culture of the abscess fluid also grew Staphylococcus aureus with the same spectrum of antibiotic sensitivity as that previously isolated. The patient made an uneventful recovery and was well at follow-up 3 months later.
Discussion
Chronic colonization by Staphyloccocus and other pathogens in the inguinal skin is well described (Szilogyi et al, 1972), but the degree of bacterial contamination required to cause a wound infection in healthy tissues is very high; however, a relatively low level may suffice in the presence of tissue trauma and haematoma (Burke, 1961). Indeed, tissue trauma, haematoma formation and possible bacterial contamination introduced at the time of percutaneous transfemoral arteriography have been implicated in an increased incidence of post-operative wound infection following arterial bypass surgery if the The British Journal of Radiology, March 1990
Case report
Figure 1. CT scans following intravenous contrast enhancement, (a) The section near the puncture site shows a soft-tissue mass posterior to the groin vessels involving the iliopsoas muscle close to its insertion and (b) the extension of the infective process is shown proximally, confined by the iliopsoas sheath, with multiple loculations.
same site was used for the pre-operative arteriogram (Landrenau & Raju, 1981). Although bacterial contamination of catheters and guidewires may be relatively common (Shawker et al, 1974), clinical infection following angiography is surprisingly rare (Herlinger, 1976). To our knowledge iliopsoas abscess has not previously been reported following femoral artery catheterization, although three cases of retroperitoneal sepsis following translumbar aortography were reported in one large series of 13 207 cases (McAfee, 1957), Sutton (1962) described a case of infection of a groin haematoma following carotid arteriography, and more recently a case of septic arthritis of the hip has been ascribed to the preceding arteriogram (Resnik et al, 1987). Seven cases of huge retroperitoneal haematoma formation following Seldinger catheterization were reported in a series of 11 402 patients (Lang, 1963) and it is unsurprising therefore that infection of the same space might occur. In our case the length of the procedure (approximately 60min) and the need for a catheter change without use of a sheath may have contributed to tissue trauma and bacterial contamination, despite full aseptic precautions and adequate compression of the puncture site following the procedure. There was no evidence of immunological incompetence in our patient, nor any predisposing factors to retroperitoneal sepsis. A standard double-wall puncture technique was used: this may have permitted access for organisms to beneath the underlying strong iliopsoas fascia, which provides a pathway for extension of the infective process proximally into the retroperitoneal space (Myers, 1982). Vol. 63, No. 747
Although infection following angiography is extremely rare, the consequences may be severe, as in our case, although our patient fortunately made a full recovery. This case report is intended to alert radiologists and clinicians to the possibility of retroperitoneal sepsis following percutaneous transfemoral arterial catheterization, and emphasizes the need for scrupulous aseptic technique during these procedures. Acknowledgments We thank Dr R. Ross-Russell for his help in allowing us to report his patient. References BURKE, J. F., 1961. The effective period of preventive antibiotic action in experimental skin incisions and dermal lesions. Surgery, 50, 161-168. HERLINGER, G., 1976. Aortography and peripheral arteriography. In Complications in Diagnostic Radiology, ed. by G. Ansell (Blackwell Scientific, Oxford), pp. 42-75. LANDRENAU, M. D. & RAJU, S., 1981. Infections after elective bypass surgery for lower limb ischaemia: the influence of preoperative transcutaneous arteriography. Surgery, 90, 956-961. LANG, E. K., 1963. A survey of the complications of percutaneous retrograde arteriography, Seldinger technic. Radiology, 81, 257-263. MCAFEE, J. G., 1957. A survey of complications of abdominal aortography. Radiology, 68, 825-838. MYERS, M. A., 1982. Dynamic Radiology of the Abdomen (Springer-Verlag, New York), p. 181. RESNIK, C. S., SAWYER, R. W. & TISNADO, J.,
1987.
Septic
arthritis of the hip: a rare complication of angiography.
225
Case report Journal of the Canadian Association of Radiologists, 38, 299-301. SHAWKER, T.
H.,
KLUGE, R.
M.
& AYELLA, R.
J.,
1974.
Bacteremia associated with angiography. Journal of the American Medical Association, 229, 1090-1092.
SUTTON, D., 1962. Arteriography (E. S. Livingstone, London), p. 54. SZILOGYI, D. E., SMITH, R. F., ELLIOTT, J. P. & VRANDECIC, M.
P., 1972. Infection in arterial reconstruction with synthetic grafts. Annals of Surgery, 176, 321-333.
The British Journal of Radiology, March 1990
1990, The British Journal of Radiology, 63, 224-226 balloon aortic valvuloplasty with transoesophageal echocardiography. American Heart Journal, 115, 460-462. FOWLES, R. E. & MASON, J. W., 1984. Role of cardiac biopsy in the diagnosis and management of cardiac disease. Progress in Cardiovascular Diseases, 27, 153-172. NELLESSEN, U., DANIEL, W. G. & LICHTLEN, P. R., 1986.
The
diagnostic value of transoesophageal echocardiography in the detection of cardiac and extracardiac masses. Zeitschrift fur Kardiologie, 75, 91-98. NEUMANN, H. P. H., HOFMANN, T., KOESTER, W., BILLMANN, P.
& KAUFFMANN, G. W., 1988. Extraction of an intracardiac catheter embolus using combined radiography and transoesophageal echocardiography. Clinical Cardiology, 11, 427-429. DI
PENNESTRI, F., LOPERFIDO, F., SALVATORI, M. P., MONGIARDO, R., MAZZARI, M., MONTENERO, A. S. &
COPPOLA, E., 1982. L'eco 2D nella guida all'esecuzione della biopsia miocardica. Cardiologia, 27, 1141-1145. ROELANDT,
J.
R.
I.
C.
&
SUTHERLAND,
G.
R.,
1988.
Oesophageal echocardiography. (Editorial) British Heart Journal, 60, 1-3. SCHLUTER, M . , LANGENSTEIN, B. A., POLSTER, J., KREMER, P., SOUQUET, J., ENGEL, S. & HANRATH, P., 1982.
Transoesophageal cross-sectional echocardiography with a phased array transducer system. Technique and initial clinical results. British Heart Journal, 48, 67-72. SEKIGUCHI, M. & TAKE, M., 1980. World survey of catheter biopsy of the heart. In Cardiomyopathy: Clinical, Pathological and Theoretical Aspects, ed. by M. Sekiguchi and M. Take (University Park Press, Baltimore and University of Tokyo Press, Tokyo), pp. 217-225.
Iliopsoas abscess: an unusual complication of femoral artery catheterization By E. J. Loveday, MRCP, K. A. Tonge, FRCR and *H. G. du Peloux Menage, BSc, MRCP Departments of Radiology and 'Neurology, St Thomas' Hospital, London SE1 7EH (Received July 1989)
We report a case of iliopsoas abscess following percutaneous transfemoral carotid angiography. To our knowledge there are no previous reports of this complication. Case report The patient, a woman aged 49, was admitted for investigation of occlusive cerebrovascular disease. She was a smoker and had a history of exopthalmic Graves' disease and thyrotoxicosis, previously treated with Iodine 131. Current medications were thyroxine, Voltarol Retard and Nifedipine Retard. Prior to the procedure, haemoglobin level was 14.2 g/dl, white cell count was 8400 x 103/ml and platelet count was 283 000 x 103/ml. Full clotting studies were normal. Carotid arteriography was performed using a modified Seldinger technique. Full aseptic precautions were taken including groin shave, cleansing with chlorhexidine, povidone iodine skin preparation and sterile drapes and gowns. A 5 F Mani catheter (William Cook Europe ApS) and a 0.035 inch straight guidewire were used during the procedure which was protracted owing to inability to catheterize the left common carotid artery. A subsequent arteriogram using a 5 F pigtail catheter revealed complete occlusion of this vessel at its origin. Compression was applied to the puncture site for 20 min. The patient was well following the procedure and was discharged home shortly thereafter. Minor bruising only was seen at the puncture site. She presented again 22 days post-investigation complaining of increasing pain in the right groin and difficulty with walking. On examination she was pyrexial; and greenish, offensive Address correspondence to Dr E. J. Loveday, Department of Radiology, St. Thomas' Hospital, Lambeth Palace Road, London SE1 7EH.
224
smelling fluid was oozing from the puncture site in the right groin. There was a 30° fixed flexion deformity of the right hip, and any attempt to straighten the leg resulted in severe pain. Haemoglobin concentration had fallen to 10.5 g/dl and the white cell count had risen to 21 000 x 103/ml. A computed tomographic (CT) scan of the abdomen and pelvis was performed, and this confirmed the clinical diagnosis of a retroperitoneal abscess involving the iliopsoas muscles, with extension down into the groin, posterior to the femoral vessels (Fig. 1). An intravenous digital subtraction angiography examination showed no abnormality of the iliac or femoral arteries and no impairment of the arterial supply to the legs. Wound swabs from the puncture site grew Staphylococcus aureus. At operation a large loculated retroperitoneal abscess was found and this was subsequently drained. Culture of the abscess fluid also grew Staphylococcus aureus with the same spectrum of antibiotic sensitivity as that previously isolated. The patient made an uneventful recovery and was well at follow-up 3 months later.
Discussion
Chronic colonization by Staphyloccocus and other pathogens in the inguinal skin is well described (Szilogyi et al, 1972), but the degree of bacterial contamination required to cause a wound infection in healthy tissues is very high; however, a relatively low level may suffice in the presence of tissue trauma and haematoma (Burke, 1961). Indeed, tissue trauma, haematoma formation and possible bacterial contamination introduced at the time of percutaneous transfemoral arteriography have been implicated in an increased incidence of post-operative wound infection following arterial bypass surgery if the The British Journal of Radiology, March 1990
Case report
Figure 1. CT scans following intravenous contrast enhancement, (a) The section near the puncture site shows a soft-tissue mass posterior to the groin vessels involving the iliopsoas muscle close to its insertion and (b) the extension of the infective process is shown proximally, confined by the iliopsoas sheath, with multiple loculations.
same site was used for the pre-operative arteriogram (Landrenau & Raju, 1981). Although bacterial contamination of catheters and guidewires may be relatively common (Shawker et al, 1974), clinical infection following angiography is surprisingly rare (Herlinger, 1976). To our knowledge iliopsoas abscess has not previously been reported following femoral artery catheterization, although three cases of retroperitoneal sepsis following translumbar aortography were reported in one large series of 13 207 cases (McAfee, 1957), Sutton (1962) described a case of infection of a groin haematoma following carotid arteriography, and more recently a case of septic arthritis of the hip has been ascribed to the preceding arteriogram (Resnik et al, 1987). Seven cases of huge retroperitoneal haematoma formation following Seldinger catheterization were reported in a series of 11 402 patients (Lang, 1963) and it is unsurprising therefore that infection of the same space might occur. In our case the length of the procedure (approximately 60min) and the need for a catheter change without use of a sheath may have contributed to tissue trauma and bacterial contamination, despite full aseptic precautions and adequate compression of the puncture site following the procedure. There was no evidence of immunological incompetence in our patient, nor any predisposing factors to retroperitoneal sepsis. A standard double-wall puncture technique was used: this may have permitted access for organisms to beneath the underlying strong iliopsoas fascia, which provides a pathway for extension of the infective process proximally into the retroperitoneal space (Myers, 1982). Vol. 63, No. 747
Although infection following angiography is extremely rare, the consequences may be severe, as in our case, although our patient fortunately made a full recovery. This case report is intended to alert radiologists and clinicians to the possibility of retroperitoneal sepsis following percutaneous transfemoral arterial catheterization, and emphasizes the need for scrupulous aseptic technique during these procedures. Acknowledgments We thank Dr R. Ross-Russell for his help in allowing us to report his patient. References BURKE, J. F., 1961. The effective period of preventive antibiotic action in experimental skin incisions and dermal lesions. Surgery, 50, 161-168. HERLINGER, G., 1976. Aortography and peripheral arteriography. In Complications in Diagnostic Radiology, ed. by G. Ansell (Blackwell Scientific, Oxford), pp. 42-75. LANDRENAU, M. D. & RAJU, S., 1981. Infections after elective bypass surgery for lower limb ischaemia: the influence of preoperative transcutaneous arteriography. Surgery, 90, 956-961. LANG, E. K., 1963. A survey of the complications of percutaneous retrograde arteriography, Seldinger technic. Radiology, 81, 257-263. MCAFEE, J. G., 1957. A survey of complications of abdominal aortography. Radiology, 68, 825-838. MYERS, M. A., 1982. Dynamic Radiology of the Abdomen (Springer-Verlag, New York), p. 181. RESNIK, C. S., SAWYER, R. W. & TISNADO, J.,
1987.
Septic
arthritis of the hip: a rare complication of angiography.
225
Case report Journal of the Canadian Association of Radiologists, 38, 299-301. SHAWKER, T.
H.,
KLUGE, R.
M.
& AYELLA, R.
J.,
1974.
Bacteremia associated with angiography. Journal of the American Medical Association, 229, 1090-1092.
SUTTON, D., 1962. Arteriography (E. S. Livingstone, London), p. 54. SZILOGYI, D. E., SMITH, R. F., ELLIOTT, J. P. & VRANDECIC, M.
P., 1972. Infection in arterial reconstruction with synthetic grafts. Annals of Surgery, 176, 321-333.
The British Journal of Radiology, March 1990
