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.     

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.     

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.     

Retro-sartorius bypass in the treatment of graft infection after peripheral vascular surgery

Extra-anatomic bypass is preferred for revascularization after removal of infected vascular grafts. The obturator canal technique has been used to bypass an infected field in the groin, although this method has not always been definitive because of several drawbacks. We present a unique method of extra-anatomic revascularization for use in such a situation. An autogenous graft is placed just below the sartorius muscle in the thigh and penetrates the iliacus muscle near the lateral end of the inguinal ligament. Limb loss and recurrent infection are prevented postoperatively. This retro-sartorius bypass technique may be a useful alternative to obturator bypass grafting in selected patients.     

Late results after extra-anatomical shunt surgery in vascular surgery

Alternative procedures were applied in high-risk patients or, in cases in which it was necessary, to bypass infected vascular beds. Some of our 113 procedures, especially the carotid-subclavian and the femoro-femoral grafts, showed excellent long-term results and wider application of these operations thus appears justified. Infected areas in the groin may be bypassed by the lateral iliaco-femoral graft as an alternative to the obturator bypass.     

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.     

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.     

The influence of groin sepsis on extraanatomic bypass patency in patients with prosthetic graft infection

Twenty-seven vascular prosthetic graft infections in 25 patients were managed from 1981 through 1990 using the principles of extraanatomic bypass through uncontaminated fields and removal of the infected prosthesis. This experience included 18 aortic, three femoral-femoral, three femoral-popliteal, two axillofemoral grafts, and one popliteal endarterectomy patch. The predominant organism wasStaphylococcus epidermidis (26%). Mean follow-up was 36 months. There was only one early and one late death, with two late amputations. Extraanatomic bypass grafts were placed in 21 of 25 patients including all 18 infected aortic grafts. Of these 21 patients, 11 (52%) experienced at least one extraanatomic bypass failure within 15 months, resulting directly in two major lower extremity amputations and two graft reinfections. Axillounifemoral bypass had a higher incidence of failure than axillobifemoral bypass (54% versus 29%). More importantly, however, extraanatomic graft failure was also associated with the presence of groin sepsis. The revision rate was 63% when the graft required circuitous tunneling to avoid groin sepsis, in contrast to a revision rate of only 17% when the graft could be anastomosed directly to the common femoral artery. Of extraanatomic bypass grafts that failed once, 63% had multiple failures. Graft removal and extraanatomic revascularization produced excellent overall results when not involving the groin. Late complications occurred more frequently when groin sepsis was present. These results suggest that, to reduce the incidence of late graft failure and amputation, more aggressive early direct reconstruction should be performed in lieu of atypical graft tunneling, especially if the extraanatomic graft has failed once and the causative organism isStaphylococcus epidermidis.Presented at the 16th Annual Meeting of the Peripheral Vascular Surgery Society, June 2, 1991, Boston, Massachusetts.     

Cross over ileo-popliteal bypass through the obturator foramen: an additional route for extra-anatomic limb blood supply

Complications and morbidity associated with vascular graft infections continue to be a major clinical problem. Ischemia and gangrene are consequences of limb circulation failure, especially in extra-anatomic, occluded and infected bypass prostheses. Infection of the tissue bed of such prostheses should be prevented. When it occurs, the use of the contralateral obturator foramen represents an alternative route in cases in which it is impossible to use the ipsilateral vessels. Prosthetic crossover reconstruction through the obturator foramen may be considered a safe and effective solution for patients with a limb threatening infection of the extra-anatomic graft and a damaged blood supply.     

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.     

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.     

Recurrence of vascular prosthesis infection: treatment by bypass of the lower part of the thoracic aorta using abdominal approach

Two years before admission a 72-year-old woman received an aortobifemoral bypass graft. When the graft became infected it was replaced by an axillofemoral bypass graft. This also became infected. In another attempt at revascularization, a bypass was installed between the lower part of the thoracic aorta and the two distal parts of the superficial femoral arteries, passing through the obturator foramen. Access to the lower part of the thoracic aorta was made through an abdominal incision, lowering the risk factors associated with such an intervention. At 18-month follow-up, the results were satisfactory; the graft was patent and not infected.     

Obturator foramen bypass--the alternative route for sepsis in the femoral triangle

Obturator foramen bypass has successfully been used to replace an infected groin graft in eight patients. Early replacement of an infected graft is recommended because of the poor results and risks associated with conservative management.     

Early transposition of the sartorius muscle for exposed patent infrainguinal bypass grafts

The traditional approach for patent and exposed and infected infrainguinal bypass grafts in the groin has included wide operative debridement and secondary or delayed primary closure. However, this has been associated with significant risk of further contamination and length of stay. The authors reviewed their experience using the wide debridement, sartorius muscle flap transposition, and primary wound closure as an alternative. During the past 5 years, they have had 50 patients with major wound necrosis or infection in the groin or thigh with the graft or native artery being exposed after debridement. This group included 28 men; 74% of the patients had hypertension, 58% had diabetes, and 20% had renal failure. The grafts were split evenly between native vein and prosthetic material. After wide debridement, closure was performed by the vascular surgeon using the sartorius muscle flap. Postoperatively, there was an 8% major amputation rate and a 12% mortality rate in the first 30 days. One patient developed a pseudoaneurysm 5 weeks after placement of the flap. This patient underwent removal of the infected polytetrafluoroethylene graft with ligation of the common femoral artery. None of the procedures have resulted in further systemic or graft sepsis. None have resulted in arterial or graft blowout. Follow-up was for an average of 18 months. Closure of groin and thigh wounds with exposed bypass graft or native artery can be safely performed with the sartorius muscle flap with excellent results. The length of stay of these patients compared to historical controls is acceptable. Furthermore, the chance of infection of the native artery or bypass may be reduced. Familiarity with this simple technique can be a valuable tool for the vascular surgeon.     

Preservation of infected and exposed vascular grafts using vacuum assisted closure without muscle flap coverage

The most widely used techniques for graft preservation after localized graft infections are muscle flap closure or antibacterial dressings and irrigations after débridement. Vacuum assisted closure (VAC) has been increasingly used for complex wounds in vascular surgery, including groin infections, but not directly on exposed bypass grafts as a stand-alone technique. We used the VAC system after wound débridement in four patients with fully exposed synthetic bypass grafts who were too unstable or risky for further operative interventions. Mean duration of VAC use was 22.8 days (range, 6 to 53 days), with time to total wound closure of 30 to 63 days (mean, 41 days). There were no reinfections with 11 to 25 months' follow-up (mean, 18.3 months). For high-risk surgical patients with a fully exposed infected prosthetic vascular graft, VAC therapy along with aggressive débridement and antibiotic therapy may be an effective alternative to current management strategies.     

Rotational muscle flaps: a new technique for covering infected vascular grafts

Twenty-one patients with established localized infection of vascular bypass grafts were treated with aggressive debridement and rotational muscle flap coverage to control graft infection. There were six gram-positive, six gram-negative, four mixed, and three fungal graft infections. Graft material included Dacron, Gore-Tex (registered trademark of W. L. Gore Associates Inc., Elkton, Md.), Dacron and Gore-Tex in combination, and saphenous vein. Twenty of 21 patients had successful preservation of graft function, local wound healing, and control of infection. There were no amputations or deaths. The one failure was caused by incomplete debridement of an infected graft segment. Aggressive debridement and rotational muscle flap coverage is an effective means of treating locally infected vascular bypass grafts.     

Secondary arterio-enteric fistulae: a surgical challenge

Ten cases of secondary arterio-enteric fistulae are described. There were nine graft enteric fistulae and one fistula involving the aortic suture line following elective resection of an infected graft. Only four of the patients initially received prophylactic antibiotics (single dose) at the original aortic reconstruction, and the vascular suture line had only been protected in two. Eight patients presented with bleeding and two with groin abscesses. One patient died before operation. Graft resection was undertaken in all patients and organisms were grown from six of eight grafts cultured. No patient died during operation but one died after 3 days. Axillofemoral bypass grafts were constructed in seven patients (four immediately after resection of prosthetic grafts and three within 4 days of operation). Only three of the eight patients who survived operation are still alive; two died of a ruptured aorta and one from a recurrent fistula. Two patients died of other causes. Four of five axillofemoral grafts in surviving patients subsequently occluded.     

Vascularised muscular flaps and arterial graft infection in the groin.

The groin is the commonest site for graft infections in vascular surgery. This is a potentially catastrophic situation as limb loss or even death occurs in a large percentage of cases. Standard teaching for treatment of infected vascular grafts is removal and extra anatomical bypass grafting whilst commencing appropriate antibiotics. This review article suggests careful scrutiny of the wound, debridement and coverage of the graft with a vascularised muscular flap is appropriate in certain situations.     

Rotational Muscle Flap Closure for Acute Groin Wound Infections Following Vascular Surgery

Since 1996, 41 patients have presented to our institution with deep but localized groin infection following bypass (30) or isolated femoral artery surgery (11). These patients were treated with antibiotics, debridement, and rotational muscle flap coverage either immediately or within a few days. Patients had one of three patterns: serous leak from a groin incision within a few days of operation (Acute, n = 10), early serous leak that later became grossly infected (Acute-observed, n = 8), or obvious purulent drainage following an initially normal, healed wound (Delayed, n = 23). Patients with early leak had nearly uniformly polymicrobial infections with a preponderance of gram-negative organisms, whereas most of those with late purulence had monobacterial infection with Staphylococcus aureus. At exploration, 26 of 41 suture lines were exposed. Rectus femoris flaps were used in 35 patients (85% of cases) for coverage, and graft preservation was attempted in all 8 vein grafts and 16 of 23 prosthetic grafts. Only one flap failed and there were no instances of anastomotic bleeding. There were no deaths directly attributable to reexploration and flap coverage, although 10 patients died during the index hospitalization. Durable coverage with no long-term evidence of infection was achieved in 24 patients with mean follow-up of 23 (range 10-66) months and another 12 had no evidence of local problems despite shorter follow-up; only 5 patients (12%) overall had evidence of persistent graft infection or unexplained bacteremia. In patients with attempted graft salvage, limb salvage was 97% at 6 months and 85% at 1 year. Although early mortality is high, deaths are not related to the flap procedure itself, local outcome is excellent, and graft and limb salvage are good; results are much worse if an initially draining wound is treated too late. Local rotational muscle flap closure is an excellent solution for acute infections involving the groin following vascular procedures.Presented at the 13th Annual Winter Meeting of the Peripheral Vascular Surgery Society, Steamboat Springs, CO, January 31-February 2, 2004.     

Lateral femoral bypass for prosthetic arterial graft infections in the groin

Objective

Prosthetic arterial graft infections (PAGIs) in the groin pose significant challenges in terms of revascularization options and risk of limb loss as well as associated morbidities. Although obturator canal bypass (OCB) has been suggested for revascularization of the extremity in these cases, moderate success rates and technical challenges have limited widespread use. Our study analyzed lateral femoral bypass (LFB) as an alternative approach for the treatment of groin PAGIs.