Thigh Compartment Syndrome Following Physician-Modified Fenestrated Endograft Aneurysm Repair

Thigh compartment syndrome (TCS), a rare but serious complication of vascular procedures, often leads to severe morbidity. Unlike leg compartment syndrome, TCS can present insidiously, delaying diagnosis and treatment. While most cases of TCS are trauma-related, vascular causes such as ischemia-reperfusion injury have been reported.

A 67-year-old male with coronary artery disease, chronic obstructive pulmonary disease, and a 50 pack-year smoking history underwent physician-modified fenestrated endograft repair of an unruptured thoracoabdominal aortic aneurysm. The procedure, performed via bilateral common femoral artery access, required upsizing the right femoral sheath to 26 French from the original 22 French because of delivery challenges. Postoperatively, the patient developed severe right lower extremity pain and loss of sensation, prompting emergent 4-compartment fasciotomy for leg compartment syndrome. Hours later, he developed new-onset thigh pain, paresthesia, and restricted movement, leading to the diagnosis of TCS. Emergent 3-compartment thigh fasciotomy was performed. The patient's postoperative course was complicated by anterior cord syndrome, paraplegia, and end-stage renal disease resulting from severe rhabdomyolysis. One year later, the patient remained on dialysis with chronic fasciotomy wounds.

This case highlights the rare occurrence of TCS following physician-modified fenestrated endograft and the potential for serious complications. Given the increased risk associated with prolonged procedures and large-diameter sheaths (≥20 French), close postoperative monitoring is crucial. Early recognition and timely intervention are key to improving patient outcomes.