Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 337-340

Extra-anatomical iliopopliteal bypass: A novel revascularization technique for infected femoral grafts and pseudoaneurysms


1 Jawahar Lal Nehru Medical College and Hospital, AMU, Aligarh, Uttar Pradesh, India
2 Department of Cardiothoracic and Vascular Surgery, Shyam Shah Medical College, Rewa, Madhya Pradesh, India

Date of Submission26-Feb-2021
Date of Acceptance18-May-2021
Date of Web Publication9-Dec-2021

Correspondence Address:
Mayank Yadav
Jawahar Lal Nehru Medical College and Hospital, AMU, Aligarh, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_32_21

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  Abstract 


Introduction: Pseudoaneurysm of the femoral artery or an infected graft in the femoral region is a very serious disease with devastating complication. The aim of this study is to describe a novel technique for its management in the form of an extra-anatomic bypass between external iliac artery (EIA) and the popliteal/distal superficial femoral artery (SFA). Methods: This is a single-center retrospective study and includes eight consecutive patients with infection of previous femoral grafts and large femoral pseudoaneurysms, in which extra-anatomic bypass between EIA and popliteal or distal SFA was done. Results: The mean age of patients in the study was 43 years. There was one 30-day postoperative mortality (12.5%) due to sepsis. The patency rate in rest of the seven patients at the end of 3 months was 100% with no major complications. Conclusion: Our technique of extra-anatomic bypass from external iliac to femoral or popliteal artery, just medial to anterior superior iliac spine beneath the inguinal ligament in the subcutaneous plane is a simple and quick approach with no major neurological or bleeding risk.

Keywords: Extra-anatomic, iliopopliteal bypass, pseudoaneurysm


How to cite this article:
Yadav M, Haseen MA, Singh SP. Extra-anatomical iliopopliteal bypass: A novel revascularization technique for infected femoral grafts and pseudoaneurysms. Indian J Vasc Endovasc Surg 2021;8:337-40

How to cite this URL:
Yadav M, Haseen MA, Singh SP. Extra-anatomical iliopopliteal bypass: A novel revascularization technique for infected femoral grafts and pseudoaneurysms. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 Jan 25];8:337-40. Available from: https://www.indjvascsurg.org/text.asp?2021/8/4/337/332049




  Introduction Top


A progressive infection of the femoral region involving the previous bypass grafts or pseudoaneurysm of the native vessels is a very serious disease which can lead to rupture of graft or vessels causing massive bleeding as well as critical ischemia in the distal limb. This devastating complication can have mortality in around one-fifth of the patients.[1] Its management includes systemic antibiotics, debridement of the infected tissue, extirpation of the graft, ligation of vessel above and below the infected region, and finally revascularization of the distal limb.

Multiple techniques of revascularization, both anatomic and extra-anatomic, have been described in literature with various merits and demerits. In this study, we want to report a novel technique of revascularization for the same. This procedure is an extra-anatomic bypass between the external iliac artery (EIA) to the popliteal artery (PA) or distal superficial femoral artery (SFA) tunneled beneath the inguinal ligament just medial to anterior superior iliac spine and then anterolaterally in the subcutaneous plane till the distal target. In this study, we will assess this method of revascularization risk, benefits as well as short-term outcome.

Methods

This is a single-center study conducted from July 2019 to September 2020. This retrospective includes eight consecutive patients with infection of previous femoral grafts and large femoral pseudoaneurysms, in which extra-anatomic bypass between EIA and popliteal or distal SFA was done.

The graft material used was 6 mm ×40 mm ringed polytetrafluoroethylene graft, Impra: BARD/Impra Inc., Tempe, AZ.

All patients were discharged on a single antiplatelet drug as well as on low-dose warfarin to keep the international normalized ratio between 1.5 and 2.5. Patients were followed up every month till 3 months to look for graft patency.

Operative technique

The patient is placed in the supine position and a wide operative field to access the abdomen, groin, and lower limb is painted and draped with infected groin region being properly excluded from the operative field.

For the retroperitoneal exposure of the iliac vessel, a transverse flank incision parallel to the inguinal ligament and around 3–4 cm above it, starting from the lateral border of rectus muscle is made. The aponeurotic portion of the external and internal oblique muscle and transverse abdominis muscles is incised or spilt. The peritoneal sac is retracted medially and iliac vessels and ureter are identified. The EIA is dissected and controlled both proximally and distally with vessel loupes. Distal SFA or proximal PA are dissected in the standard fashion in lower medial thigh region. The graft is tunneled beneath the inguinal ligament just medial to anterior superior iliac spine and then anterolaterally and subsequently medially in the subcutaneous plane to reach the distal site. Injection heparin is given intravenously (100 units/kg) and after 3 min proximal EIA is clamped, and proximal anastomosis of graft with EIA is done using prolene 6-0 in end-to-side fashion [Figure 1]. EIA is ligated distally to anastomosis as low as possible. The graft is then anastomosed to the distal SFA or proximal PA in the similar fashion [Figure 2]. After proper closure of wound and dressing, the infected groin wound is then debrided, and any previous graft present is taken out, and the vessel is ligated both distally and proximal to it. The wound is then approximated after proper debridement [Figure 3].
Figure 1: Operative picture of the proximal anastomosis of the graft with the external iliac artery

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Figure 2: Operative picture of the distal anastomosis of the graft with the popliteal artery

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Figure 3: Postoperative picture of the closed wound of incisions and the debrided infected wound

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  Results Top


The study consisted of eight patients who underwent extra-anatomic bypass between EIA and popliteal or distal SFA in patients with infected femoral grafts or large femoral pseudoaneurysms. Etiological factor associated with above patients are listed in [Table 1].
Table 1: Etiological factors of patients

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The mean age of patients in this study was 43 years. Other demographic data and clinical characteristics observed in these patients are summarized in [Table 2].
Table 2: Demographic and clinical characteristics of patients

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Operative mortality

The overall 30-day postoperative mortality rate was 12.5% (one patient). The reason of patient's death was sepsis-induced multiorgan dysfunction on postoperative day 17.

Patency

Of the remaining seven patients, all were followed for a short follow-up period of 3 months every monthly. All the seven patients were found to be having well flowing graft with patency rate of 100% at 3 months postoperatively.

Complications

In the 3-month follow-up period, there were no major complications. Minor complications in the form of superficial infection were present in one patient; deranged PT INR was present in two patients but with no major issue such as thrombosis or bleeding diathesis.


  Discussion Top


In the course of time, multiple techniques have been developed to maintain the vascular continuity in the limb distally in patients with infected femoral grafts or large femoral pseudoaneurysms.

In 1961, Blaisdell first described a bypass from the lower descending thoracic aorta, placing it retropleurally then tunneled posterior-laterally around the iliac crest, beneath the sartorius muscle, and ending in the femoral artery. He used this route to bypass an infected aortic bifurcation prosthesis.[2] Later on, Blaisdell modified his own procedure by tunneling the graft from the axillary artery to a distal target such as the femoral or PA subcutaneously.[3] The long graft length was theoretical responsible for low patency rate requiring high dose of oral anticoagulation.

Shaw and Baue then in 1962 described a more anatomical route to bypass the femoral triangle by tunneling a graft through the obturator foramen.[4] This procedure is beneficial in patients requiring radical resection such as malignancy, ischemic skin flaps, radiation skin necrosis, and trauma with loss of adequate soft tissue to cover exposed femoral vessels.[5],[6],[7],[8] Patients in whom femoral sepsis extends medially and deeply into the adductor compartment, this procedure is not suited. Other disadvantage of this technique is risk of operative injury to obturator nerve, artery, and even bladder.[9],[10]

Wolf and Pate in 1967 introduced a technique that included a graft anastomosed to iliac artery taken out through the rectus sheath and tunneled subcutaneously directed toward iliac wing and subsequently to the distal anastomotic site.[11] The extensive infective process involving the superior portion of the femoral region precluded using this approach.

Another technique which can be used is a gluteopopliteal bypass which is a completely posterior approach.[12] The superior gluteal artery is being used as inflow vessel in the gluteal region for proximal anastomosis, and then the graft is tunneled through the gluteal muscles, upper thigh, and finally to the PA. The disadvantage of this procedure is the concern over the adequacy of the inflow vessel, as it is a distal branch of internal iliac artery and moreover affected with atherosclerotic changes.

Brzezinski[13] in 1989 was the first to describe a bypass through the iliac wing which was further modified by donayre.[14] In this technique, arterial inflow was taken from iliac vessel then tunneled through the iliac wing, tunneled deep to the muscular envelope, and then to the distal anastomotic site. The advantage of this technique is that it provides a direct and short route to the distal site and thus maximize arterial flow distally. Moreover, its deep course protects it from external pressures as well as superficial infected area, especially when the infection process has spread medially into the adductor area making the use of the obturator foramen bypass difficult. The disadvantage of this technique is that it requires an extra technical issue to work at a deeper area requiring extraoperative time in fragile patients. There is also a risk of injury to terminal branch of superior gluteal artery.

In this study, we have used this extra-anatomic subcutaneous ilio-popliteal/iliofemoral bypass technique of tunneling the graft from proximal iliac anastomotic site, beneath the inguinal ligament just medial to the anterior superior iliac spine, directing it posterolaterally on the thigh in subcutaneous plane, and subsequently routing it medially to the distal anastomotic site. The advantage of this technique is that it is easy to perform, takes comparatively much less operative time than the other techniques. This technique does not endanger any risk to major nerve or vessels. We advocate the use of this technique as it is simple, easily reproducible and can be performed quickly in these patients. The disadvantage of this technique is that the graft is tunneled in the subcutaneous plane making it vulnerable to infection. Moreover, in patients in whom the infectious process has spread laterally on the thigh, this technique is not suitable.


  Conclusion Top


Various procedures to revascularize the lower limb in the presence of infection and sepsis in the femoral triangle region or in the presence of infected femoral graft have been described in the past. Our technique of extra-anatomic bypass from iliac to femoral or PA, just medial to anterior superior iliac spine beneath the inguinal ligament in the subcutaneous plane, is a simple and quick approach with no major neurological or bleeding risk. The main advantage of this approach is that it is easily reproducible and can be performed rapidly in these fragile patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bunt T. Synthetic vascular graft infection. I: Graft infections. Surgery 1983;93:733-46.  Back to cited text no. 1
    
2.
Blaisdell FW, Demattei GA, Gauder PJ. Extraperitoneal thoracic aorta to femoral bypass graft as replacement for an infected aortic bifurcation prosthesis. Am J Surg 1961;102:583-5.  Back to cited text no. 2
    
3.
Blaisdell FW, Hall AD. Axillofemoral artery bypass for lower extremity ischemia. Surgery 1963;54:563-71.  Back to cited text no. 3
    
4.
Shaw RS, Baue AE. Management of sepsis complicating arterial reconstructive surgery. Surgery 1963;53:75-86.  Back to cited text no. 4
    
5.
DePalma RG, Hubay CA. Arterial bypass via the obturator foramen. An alternative in complicated vascular problems. Am J Surg 1968;115:323-8.  Back to cited text no. 5
    
6.
Hegarty JC, Linton PC, McSweeney ED Jr. Revascularization of the lower extremity through the obturator canal. Arch Surg 1969;98:35-8.  Back to cited text no. 6
    
7.
Guida PM, Moore SW. Obturator bypass technique. Surg Gynecol Obstet 1969;128:1307-16.  Back to cited text no. 7
    
8.
van Det RJ, Brands LC. The obturator foramen bypass: An alternative procedure in iliofemoral artery revascularization. Surgery 1981;89:543-7.  Back to cited text no. 8
    
9.
Sheiner NM, Sigman H, Stilman A. An unusual complication of obturator foramen arterial bypass. J Cardiovasc Surg (Torino) 1969;10:324-8.  Back to cited text no. 9
    
10.
Wood RF. Arterial grafting through the obturator foramen in secondary hemorrhage from the femoral vessels. Angiology 1982;33:385-92.  Back to cited text no. 10
    
11.
Wolf RY, Pate JW. Trans-rectus sheath arterial bypass for aorto-iliac sepsis. Ann Surg 1967;165:283-5.  Back to cited text no. 11
    
12.
Topalov I, Marinov G. A new posterior approach for an extra-anatomical arterial bypass for lower extremity revascularization (gluteopopliteal bypass). Eur J Vasc Surg 1993;7:454-6.  Back to cited text no. 12
    
13.
Brzezinski W, Callaghan JC. Trans-iliac bypass for infected femoral end of an aorta-femoral graft. Can J Surg 1989;32:121-3.  Back to cited text no. 13
    
14.
Donayre CE, Ewbanks P, Ayers B, de Virgilio C, Klein SR. Iliac to popliteal artery bypass through the iliac wing: An alternative extracavitary route for management of complex groin injuries. Ann Vasc Surg 1999;13:209-15.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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