Obturator bypass: a classic approach for the treatment of contemporary groin infection

As the number of cardiac and interventional radiologic procedures has risen, the frequency with which surgeons are called to treat groin complications has increased. Infectious groin problems that often involve foreign prosthetic material or remnants of percutaneous femoral closure devices are particularly challenging and require control of bleeding, removal of foreign material, wide debridement, and sometimes arterial resection. Management of the consequential limb ischemia in such cases is controversial. The purpose of this study is to review the utility of extra-anatomic common femoral bypass through the obturator foramen (obturator bypass) as a method of treating limb ischemia after arterial groin infection. From July 1992 through June 2001 a total of 12 patients (six male) presented with severe vascular infections of the groin and underwent obturator bypass. Infections occurred as a consequence of an isolated vascular graft infection (nine) or after a percutaneous interventional femoral access procedure (three). Patients presented with systemic sepsis and a draining sinus (six), infected pseudoaneurysm (two), or hemorrhage (four). Treatment included debridement of the groin wound, sartorius muscle flap coverage of the femoral vessels, antibiotics and synthetic (eight polytetrafluoroethylene and four Dacron) obturator bypass via a lower abdominal extraperitoneal incision from an aortobifemoral bypass graft limb to the superficial femoral artery (six), native iliac to femoral artery (three), iliac to popliteal artery (two), and aortobifemoral bypass limb to the popliteal artery (one). Graft patency and limb salvage were assessed by Kaplan-Meier life table analysis. There were two (17%) deaths (multisystem organ failure at postoperative days 9 and 6) and four major complications (25%) requiring reoperation in the first 30 days. Ten patients (83%) survived, healed their groin wounds, and are infection free. With a mean follow-up of 37 months graft patency and limb salvage at 60 months were 80 and 60 per cent, respectively. There were no late graft infections. We conclude that the obturator bypass is an effective and durable means of revascularization in the presence of the septic groin. This procedure belongs in the armamentarium of all surgeons managing these complications.     

血栓闭塞性脉管炎合并动脉硬化闭塞导致下肢缺血的手术治疗

目的 探讨下肢血栓闭塞性脉管炎(thmmboangiitis obliterans,TAO)合并动脉硬化闭塞症(arteriosclerosis obliterans,ASO)手术治疗效果.方法 回顾性分析2007年治疗的TAO合并ASO 6例患者的资料.2例行腹主动脉切开取栓+内膜剥脱+腹主动脉-股深动脉人工血管旁路移植-胭动脉人工血管-小腿动脉自体大隐静脉旁路移植术,1例行腹主动脉切开取栓+内膜剥脱+腹主动脉-右股深动脉人工血管旁路移植-膝下胭动脉人工血管旁路移植术;1例行左髂总动脉-左股深动脉人工血管旁路移植一胫前动脉自体大隐静脉原位移植术,1例行左侧人工血管切开取栓+左股深动脉成形-膝下腘动脉人工血管旁路移植术,1例行右股总动脉-左股总动脉人工血管旁路移植-胫后动脉自体大隐静脉旁路移植术.结果 5例患者术后恢复顺利,1例于术后当天出现股动脉-腘动脉人工血管和远段的大隐静脉桥血栓形成,立即再次手术行人工血管和大隐静脉切开取栓术,并同时行胫后动静脉吻合.6例患者均痊愈出院,无死亡病例.5例患者的下肢远端静息痛完全缓解,1例部分缓解.足部溃疡的2例创面明显缩小,无感染发生.所有患者得到随访,平均随访为6.5个月,3例足部溃疡愈合.1例术后3个月出现左股部切口感染,最终行膝上截肢处理,残端一期愈合.其他5例患者的移植血管通畅,症状缓解.结论 对TAO合并ASO患者如果手术治疗方式恰当,可以取得比较好的疗效.     

Der extraanatomische transiliakale Bypass

Infections of the groin following alloplastic vascular reconstruction still remain a challenge for the vascular surgeon. In a 48-year-old patient who underwent an extra-anatomic obturator bypass for tumor resection of his left groin, a graft infection occurred. Healing was achieved by performing a new extra-anatomic bypass transosseously through the iliac wing with secondary explantation of the infected grafts. In the case of severe infections or injured tissue in the groin or small pelvis caused by trauma, prior operations or radiation therapy, a transiliac bypass is a simple and safe alternative.     

Obturator foramen bypass for infected blocked groin graft - A case report

Limb revascularization is a challenging situation when groin graft gets infected. A young male patient aged 28 years who had road traffic accident with lacerated left external iliac artery was treated with ilio-femoral graft. Three months after he presented with infected, occluded illio- femoral graft with critical limb ischemia. He was successfully managed with antibiotics, illio-popliteal graft passed through obturator foramen. Infected graft was excised.Obturator bypass should be considered in case of infected groin graft.     

Femorofemoral bypass through the perineum for infection complicating arterial revascularization of the lower limb

Of 587 prosthetic arterial constructions performed between 1980 and 1984 on the aorta and lower limbs, 25 patients were operated on for sepsis. A total of 37 operations were performed, six of which were femorofemoral crossover bypasses through the perineum. Prosthetic material was used in one case and vein in five. The host vessel was the contralateral iliac or femoral artery, the contralateral limb of an aortobifemoral bypass, or the contralateral limb of an axillofemoral bypass in two cases each. The recipient vessel was the profunda femoris artery in four cases, the popliteal artery in one case, and the profunda femoris and popliteal arteries sequentially in one case. Indications for perineal bypass included an infected pseudoaneurysm in the femoral triangle following a femoropopliteal (one case) or aortofemoral bypass (five cases). In two instances, sepsis was bilateral and also required an axillofemoral bypass. Excepting one postoperative death, early results were satisfactory as infection disappeared and arterial reconstructions remained patent in all other cases. This technique should have its place in the armamentarium of extraanatomic bypasses along with other techniques such as the axillofemoral, prepublic femorofemoral crossover, and obturator bypasses. The best indication for perineal bypass is when vascularization of a lower limb from the contralateral side is necessary because of infection in the femoral triangle.     

Femoral artery to prosthetic graft anastomotic dehiscence owing to infection: successful treatment with arterial reconstruction and limb salvage

A 66-year-old man had foot gangrene and a fixed contracture of the knee following two failed femoropopliteal bypasses, one with vein and one with polytetrafluoroethylene (PTFE). An external iliac to anterior tibial artery bypass and skeletal traction via the os calcis resulted in limb salvage and successful normal ambulation. After 3 months, he ruptured the infected femoral anastomosis of the failed PTFE femoropopliteal bypass with external bleeding. The use of arteriography and a balloon catheter to obtain proximal control allowed arterial repair, removal of the graft, and preservation of flow within a patent common and deep femoral artery. This flow preservation maintained the viability and function of the limb when the anterior tibial bypass closed 4 years later, and the limb continues to be fully functional 3 years later. Aggressive secondary attempts at limb salvage are worthwhile even in unfavorable circumstances.     

Surgical treatment of methicillin-resistant Staphylococcus aureus infection following infrainguinal arterial reconstruction.

A 64-year-old man was referred to our hospital with Methicillin-resistant Staphylococcus aureus (MRSA) infection following infrainguinal arterial reconstruction. As repeated MRSA sepsis occurred, we decided to remove the infected graft with distal revascularization via circuitous graft tunneling to avoid serious infections and allow limb salvage. An iliofemoro bypass was performed via an extra-anatomical bypass, from just below the iliac crest into the musculus quadriceps femoris using an 8 mm-ringed polyester gelatin polypropylene tube graft, with complete debridement of a groin infection. Postoperative 3-dimentional CT angiography revealed that the prostheses was patent and the patient had an uneventful postoperative course. We concluded that this extra-anatomical bypass was a safe procedure and an excellent option for patients with an infected vascular prosthetic graft in the groin after previous revascularization, like in our case with no available autogeneous vein grafts.     

Crossover ilioprofunda reconstruction: an expanded role for obturator foramen bypass.

The standard obturator foramen bypass extends from the aorta or iliac artery to the ipsilateral superficial femoral or popliteal artery. This operation has been both effective and versatile as an indirect bypass procedure for circumventing difficult vascular problems in the femoral triangle. A case is presented of a patient whose limb was salvaged by an obturator foramen bypass from the contralateral iliac artery to the profunda femoris artery. This unique case is compared to other published cases to emphasize the potential advantages of the profunda femoris as the preferred graft outflow in selected cases of arterial reconstruction through the obturator foramen.     

Combined semiclosed iliac endarterectomy and distal arterial reconstruction for multilevel arterial disease

Semiclosed iliac endarterectomy in combination with an infrainguinal vascular reconstruction has been used over the past decade in the treatment of lower-limb ischaemia. Although the early results of this combination of operations were known, the durability of the external iliac endarterectomy had not been assessed and so an effort was made to review all surviving patients by duplex scanning. Between 1985 and 1993, 48 patients (51 limbs) underwent combined semiclosed iliac endarterectomy and infrainguinal vascular reconstruction for iliac and femoropopliteal occlusive disease. Some 49% of operations were performed for limb salvage. An iliofemoral bypass graft was required twice because of failure of the endarterectomy. A variety of distal arterial reconstructions was employed. One patient required a major amputation and there were two deaths. Mean (s.d.) ankle/brachial indices (ABI) rose from 0.54 (0.14) to 0.85 (0.25) after surgery. Some 85% of the patients who underwent operation for claudication became symptom free; 83% of patients who underwent operation for limb-threatening ischaemia became symptom free or improved to mild claudication during an average of 29 months follow-up. During the follow-up period five patients underwent a further procedure because of restenoses of the external iliac artery. A duplex scanning study was performed in 22 of the 51 limbs an average of 36 months after surgery. External iliac artery stenotic lesions were found in the area of the endarterectomy in three patients. Endarterectomy of the external iliac artery from the groin is an alternative for some patients with iliac arterial disease. In a patient scheduled for an infrainguinal bypass, when an unexpectedly greater degree of athermoma is found at operation in the common femoral and external iliac arteries, this operation may be performed. The durability of the operation as assessed by follow-up duplex scan is quite acceptable.     

Supraceliac aortofemoral bypass

Increasing numbers of patients with aortoiliac disease are seen with contraindications to standard infrarenal aortofemoral reconstruction. Although axillofemoral bypass is possible in these patients, the decreased patency rate associated with this operation makes alternate procedures desirable. This report details our experience with prosthetic bypass from the supraceliac aorta to the femoral arteries in seven patients with limb-threatening ischemia of the lower extremity, all of whom had undergone multiple previous aortic operations. The operations were performed through thoracoabdominal or flank incision, and the preferred graft configuration consisted of a single Dacron tube from the aorta to the left groin with a standard subcutaneous femorofemoral graft to the right groin. No surgical deaths occurred. At 3 1/2 years' mean follow-up, there has been one graft limb occlusion that resulted in amputation for an overall life table patency and limb salvage rate of 93%. We conclude that supraceliac to femoral artery bypass is a useful procedure for the treatment of patients who have had multiple previous aortic reconstructions fail.     

Transluminal iliac angioplasty with distal bypass surgery in patients with critical limb ischaemia

Transluminal balloon angioplasty of the iliac artery was combined with a distal bypass graft procedure in 25 patients with critical ischaemia of the lower limb. Eleven patients had angioplasty in the operating theatre before a vascular graft and the remaining 14 patients had percutaneous transluminal angioplasty performed in the X-ray department before bypass surgery. The distal bypass grafts were 20 femoropopliteal and five femorofemoral grafts. Two patients died in the immediate postoperative period. Follow-up of patients ranged from 2 to 26 months with a graft patency of 63% at 12 months and 50% at 24 months but successful limb salvage rate of 75% at 12 and 24 months. Six patients required major amputations for failure of limb salvage. Transluminal iliac angioplasty is a valuable adjunct to distal bypass surgery by improving arterial inflow without the requirement for major aorto iliac surgery.     

Comparison of iliofemoral and femorofemoral crossover bypass in the treatment of unilateral iliac arterial occlusive disease

Between 1981 and 1988, 74 synthetic crossover bypass grafts were inserted for unilateral iliac arterial occlusive disease. In 32 patients the bypass procedure was iliofemoral and in 42 femorofemoral. The cumulative patency rate at a mean of 2.7 years was 79 per cent in both groups. There was no significant difference in either postoperative mortality rate or duration of hospital stay. Iliofemoral bypass may offer significant advantages over the femorofemoral approach. In particular it avoids a groin incision in the donor limb, leaving the common femoral artery intact for subsequent angioplasty or reconstruction should proximal stenotic disease develop in the donor iliac vessel.     

Outcomes in the management of vascular prosthetic graft infections confined to the groin: A reappraisal

The management of vascular prosthetic graft infections confined to the groin continues to be controversial. To critically evaluate this problem, we reviewed the records of our vascular registry from December 1992 through February 1995 and found 17 incidences of groin sepsis involving a vascular prosthesis in 10 patients. These included a proximal prosthetic femoropopliteal bypass (n=6), an aortobifemoral graft limb (n=5), an ileofemoral bypass (n=3), a prosthetic femoral patch (n = 2), and an aortofemoral/femorofemoral bypass (n=1). The mean age of these patients was 65 years. Six patients were diabetic, four were on systemic steroids, and two were diabetic and on steroids. All infections were Szilagyi grade III including three in which the patients presented with local hemorrhage. Treatment consisted of irrigation, radical debridement with or without in situ graft replacement, and local rotational muscle flap coverage in nine cases, graft excision with extra-anatomic (obturator ileofemoral bypass) graft replacement in six cases, and excision alone in two cases. Of the 17 infections treated operatively and followed from 1 week to 18 months (median 5 months), eight (47%) showed no evidence of recurrence, six (35%) recurred, two (12%) caused early death, and one resulted in a thrombosed graft requiring extra-anatomic reconstruction. Of the nine infected grafts treated locally with muscle flaps, six showed recurrent infection from 3 weeks to 15 months and one thrombosed for a total local treatment failure rate of 78%. Only two grafts are free of infection at 4 and 5 months, respectively. Of the six incidences of infection treated with obturator bypass, four (66%) are free of infection and two resulted in patient death; both infections treated with excision alone were eradicated but resulted in a major lower extremity amputation. These data question the growing acceptance of debridement and local muscle flap coverage for the treatment of all prosthetic vascular graft infections confined to the groin, especially in patients who are diabetic or on systemic steroids.Presented at the Twentieth Annual Meeting of the Peripheral Vascular Surgery Society, New Orleans, La., June 10, 1995.     

Arterial reconstruction with deep leg veins for the treatment of mycotic aneurysms

PURPOSE: Mycotic pseudoaneurysms (MPA) remain challenging clinical problems. Primary surgical management includes control of hemorrhage and debridement of the infected arterial wall. Because critical ischemia may develop after arterial resection, revascularization has been a secondary goal of treatment. Standard anatomic graft placement or prosthetic bypass grafting has been compromised by a high rate of recurrent infection. Extra-anatomic reconstruction is preferred, with the basic goals being threefold: (1) the use of autogenous graft material to reduce the risk of reinfection; (2) the avoidance of significant size mismatches; and (3) graft placement that is anatomically inaccessible, because drug abuse causes many of these lesions. This study reviews a recent series of MPAs applying these treatment goals. METHODS: In a 2-year period, the superficial femoral and proximal popliteal veins were used in the repair of eight MPAs of the common femoral (5), common iliac (1), and brachial (1) arteries, and the infrarenal aorta (1). Most patients (5 of 7) were known intravenous drug users, who had a painful pulsatile mass in an injection area. Two patients had systemic sepsis, one patient with an infected common iliac pseudoaneurysm and one patient with an MPA of the infrarenal aorta. The diagnosis of MPA was made by means of duplex/computed tomography scanning and confirmed by means of arteriography in all cases. RESULTS: Obturator bypass grafting was performed by using a reversed deep leg vein in the five femoral MPAs. An ilioiliac, cross-pelvic bypass grafting procedure with a deep vein was used to repair an MPA of the common iliac artery. A deep vein was also used as a "pantaloon" aortobiiliac graft and for a brachial artery repair. Staphylococcus aureus was revealed by means of cultures in nearly all cases. Distal arterial perfusion was normal after reconstruction. Patients had no significant postoperative leg swelling. No new venous thrombosis below the level of deep vein harvest was revealed by means of duplex scanning. There were no septic complications. CONCLUSION: The superficial femoral/popliteal veins may be particularly useful for limb revascularization in patients with MPAs. This autogenous conduit provides an excellent size-match and a suitable length for reconstruction, because peripheral, axial arteries are generally affected. No clinically significant limb morbidity was related to deep vein removal. Late follow-up is challenging in such cases, but will be required to accurately determine the durability of this strategy.     

Remote bypass grafts for managing infected popliteal artery lesions.

Infected false aneurysms of the popliteal artery may complicate vascular repairs for trauma or primary arterial disease. Adequate debridement and drainage are necessary if the limb is to be salvaged, but direct arterial grafting through the infected area cannot be performed safely. Vascular reconstruction can be accomplished by performing a femoropopliteal or iliopopliteal bypass through a lateral approach, then the infected artery can be removed safely through separate incisions. This technique was used successfully in managing four patients with infected popliteal artery pseudoaneurysms.     

Transobturator aorto-profunda femoral artery bypass using the direct medial thigh approach

We present a novel technique for aorto-profunda femoral artery bypass using both the obturator foramen and the direct medial thigh approach to the profunda femoral artery in a patient with an infected femoral graft and limb-threatening ischemia. This patient has undergone multiple bypass grafts to salvage function of his lower extremities, but these standard anatomic and extra-anatomic bypasses had failed because of graft infections. The technique as well as the surgical anatomy are described. The combination of the transobturator aorto-profunda femoral artery bypass and the direct medial approach to the profunda femoral artery is technically feasible, provides adequate outflow for limb salvage in selected patients with good collateral arteries, offers acceptable long-term patency, and is particularly useful when the groin is hostile to dissection or graft material and the superficial femoral and popliteal arteries are occluded.     

Deep leg vein reconstruction for an isolated mycotic common iliac artery aneurysm in an HIV-positive patient

Isolated mycotic common iliac artery aneurysms are rare, and as such, there is no consensus opinion on management. Traditional surgical options include resection with extra-anatomic bypass, placement of allograft or antibiotic treated synthetic graft, or autogenous vein reconstruction. We report the case of a 46-year-old, human immunodeficiency virus-positive male who presented with a recurrent pneumonia and new onset of right lower quadrant abdominal pain associated with right lower extremity swelling. computed tomographic scan revealed an isolated 9.5 cm right common iliac artery aneurysm with no evidence of rupture. Preoperative blood cultures grew out Streptococcus pneumoniae. Operative repair included aneurysm resection and reconstruction using an autogenous femoropopliteal vein interposition graft from the ipsilateral thigh. The patient had an uneventful recovery with resolution of his lower extremity swelling and a normal duplex exam at follow-up. Large mycotic common iliac artery aneurysms can be successfully treated with aneurysm resection and reconstruction using an autogenous femoropopliteal vein conduit. This technique obviates the need for extra-anatomic bypass or other forms of reconstruction using prosthetic material.     

Use of superficial femoropopliteal vein for suprainguinal arterial reconstruction in the presence of infection

BACKGROUND: Conventional treatment of mycotic aneurysms or graft infections of the aortoiliac segment by in situ or extra-anatomic prosthetic reconstruction has a high mortality and morbidity rate, with a substantial risk of persistent graft infection. The use of autologous vein may reduce this. METHODS: Eleven patients with suprainguinal arterial infections including two with mycotic aortic aneurysms, four with aortic graft infections, four infected femorofemoral grafts and an infected axillofemoral graft were treated by debridement and in situ reconstruction with autologous superficial femoropopliteal vein. All patients received appropriate antibiotic therapy and were followed by regular postoperative duplex imaging. Preoperative femoral vein duplex imaging was performed in eight of the 11 patients. RESULTS: Ten of the 11 patients survived with a functioning graft and without limb loss or evidence of infection at 4-33 months. One patient died from myocardial infarction after operation. Three patients had minor swelling of one leg. Four patients required subsequent angioplasty of anastomotic stenoses detected by duplex surveillance. CONCLUSION: Superficial femoropopliteal vein is an excellent conduit for suprainguinal reconstruction in the presence of infection. Duplex imaging is useful for confirming the suitability of deep veins for use as a graft and for postoperative surveillance.     

Critical limb ischemia in a patient with von Recklinghausen's neurofibromatosis. Report of a case

A 42-year-old woman complicated with neurofibromatosis underwent both balloon percutaneous transluminal angioplasty (PTA) of the iliac artery and femoropopliteal (FP) bypass grafting for critical lower limb ischemia. Seven months after the initial intervention, a recurrence of stenosis in the iliac artery and at the anastomoses of the FP bypass necessitated both PTA and a repeat thrombectomy and finally resulted in the amputation of her left thigh. This is a rarely documented case of chronic arterial occlusion associated with neurofibromatosis, in which the prognosis of arterial reconstruction for such patients is suggested to be poor.     

Extraperitoneal unilateral iliac artery bypass for chronic lower limb ischaemia

Extraperitoneal unilateral iliac artery bypass was used to treat chronic lower limb ischaemia in 105 patients (110 operations). This represented 20% of all operations for aorto-iliac disease. Unilateral iliac bypass was the preferred primary procedure for 99 operations, and was used to correct complications in one limb of a prior aortic bifurcation graft in the other 11. Ipsilateral femoropopliteal vein grafts were also performed in 45 legs (43%), prior to the iliac bypass in 18, as a synchronous operation in nine, and at a later date in 18 legs. This was a much higher proportion of combined operations than for patients by aortic bifurcation grafts (12%). Only 5 patients later required further proximal surgery, one for a blocked graft and four for contralateral iliac disease. The cumulative patency rate in surviving patients was 91% at 3 years. For the claudicants and for iliofemoral bypass operations, only one graft occluded, within 5 years, and no grafts occluded for operations where the superficial femoral artery was patent. The cumulative patency rates at 3 years were 85% for patients with critical ischaemia, 82% for ilioprofunda bypass operations, and 88% for operations where the superficial femoral artery was occluded. The cumulative foot-salvage rate in surviving patients initially treated for critical ischaemia was 77% at 3 years. The cumulative survival rate was 90% at 3 years. Extraperitoneal unilateral iliac bypass is now preferred as the primary operation for patients with apparent unilateral iliac disease causing severe ischaemia, if balloon dilatation is not appropriate or has failed.