Gluteal and Thigh Compartment Syndrome after Open Abdominal Aortic Aneurysm Repair

A 55-year-old male underwent elective aorto-bi-iliac bypass for asymptomatic abdominal aortic aneurysm (AAA) and left common iliac artery (LCIA) ectasia. Intraoperative assessment of the left foot revealed persistent ischemia after reperfusion, and this was thought to be related to a dissection flap or technical issue at the left limb anastomosis. To address this, a jump bypass to the left internal iliac and left common femoral artery was performed, requiring re-clamping of the left iliac system. On postoperative day (POD) 1, the patient had oliguria and rising creatinine kinase levels to 45,000 U/L. On POD 2, the patient complained of a "charley horse" in his left groin and thigh. Suspecting compartment syndrome (CS), pressures were measured. The maximus compartment pressure was 20 mm Hg, minimus and medius compartment pressure were 22 mm Hg, and the posterior thigh compartment pressure was 50 mm Hg. Diagnosis of left thigh and gluteal CS was made. The patient was taken to the operating room for emergent fasciotomy of the buttock and thigh (Fig 1). Postoperatively, the patient had recovery of proximal lower extremity function. CS is a rare complication of elective aortic surgery, and more commonly affects the leg rather than proximal muscle groups. Prolonged ischemia due to clamping of the aorta results in hypoxic damage to muscle tissue, loss of membrane permeability, and interstitial edema. Reperfusion causes a buildup of reactive oxygen species which further damages cell membranes. These changes cause a large rise in the compartment pressure due to the inability of the fascial compartments to expand, and further ischemia and necrosis ensues. Emergent thigh and gluteal fasciotomy is indicated when proximal CS is diagnosed. To release the anterior and posterior compartments of the thigh, a single anterolateral incision is made to expose the vastus lateralis muscle and the lateral intermuscular septum. The lateral intermuscular septum is then incised to decompress the posterior compartment. The incision is extended proximally to release the gluteal compartments, with splitting of the gluteus maximus to decompress the medius/minimus compartment. Clinicians should consider gluteal and thigh CS in cases where there is prolonged or repeated aortic or iliac artery clamping, especially when unusual or proximal lower extremity symptoms occur postoperatively. Our patient received emergent decompression fasciotomy of the buttock, thigh, and leg. He returned to the operating room 3 days later for wound debridement and irrigation with partial closure of his wounds.