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

[Treatment of radiation-induced iliofemoral arterial complications with groin radionecrosis]

Long-term iliofemoral complications induced by radiation include vascular (arterial and venous) lesions, nervous lesions and soft tissue loss that can be cutaneous and subcutaneous and potentially lead to radionecrosis with vessel exposure. We present five cases of groin radionecrosis. There were three men and two women (age 30-73 years). Radiotherapy had been delivered 15 years earlier in three cases, and 2 years earlier in two cases. Symptoms were intermittent claudication (n=1), critical ischemia (n=1), and septic hemorrhage (n=1). Two patients had no vascular symptoms. Four patients underwent scheduled surgery after complete cardiac and cardiovascular evaluation with duplex-Doppler, CT scan and/or intra-arterial angiography. One woman underwent emergency surgery after septic hemorrhage of a previous in situ femoral revascularization fashioned 2 months earlier. Revascularization was achieved with trans-iliac (n=3), trans-muscular (n=1, and in situ (n=1) iliofemoral bypass. A retroperitoneal approach with section of large muscles was used. In three cases, a trans-iliac route was used by perforating the iliac wing with a 8-mm PTFE graft. Proximal anastomosis was done on the abdominal aorta (n=1) and the homolateral common iliac artery (n=2). Distal anastomosis was done on the distal profunda artery and popliteal artery (n=1) and on the distal femoral superficial artery (n=2). In two cases, an iliofemoral bypass was done with a 7-mm PTFE vascular graft. The proximal anastomosis was done on the proximal external iliac artery and the distal anastomosis on the proximal superficial femoral artery. A plastic procedure was performed in four cases. Three patients had a homolateral (n=1) or controlateral (n=2) rectus abdominis flap. In one case, plastic coverage was done with an antebrachial flap (Chinese flap), which has been released at 6 weeks. One patient had post-radiotherapy iliofemoral vascular disease, but there was no vascular exposure, and no plastic coverage was necessary. The postoperative course was uneventful in four cases. The patient treated with an in situ bypass developed septic hemorrhage at day 10, requiring revision. The patient died of multiple organ system failure, with a patent graft and a viable flap. The other four patients had no early or late complications. These patients have been followed annually for clinical examinations and duplex scans, and angio-scans. One patient died of ischemic heart disease. The three other patients are alive with a patent bypass with 11, 8 and 3 years follow-up. One patient had a late occlusion of the bypass treated by thrombectomy after 7 and 10 years. In conclusion, patients with femoral radionecrosis can be treated by an extra-anatomic bypass, with plastic coverage. The trans-iliac is a relatively simple and safe procedure.

[Femoral-femoral bypass crossed with perineal under-scrotal tunneling for a serious infection of the Scarpa triangle]

Nous décrivons dans cet article une technique de revascularisation des patients ayant une infection de prothèse vasculaire sus-crurale au niveau dutriangle de scarpa, et qui minimise le risque d'infection récurrente du greffon. Cette technique consiste en un pontage fémoro-fémoral croisé avec un tunnel périnéal sous-cutané loin du scarpa infecté que le tunnel classique sus-pubiensous-cutané ne permet pas. Nous rapportons le cas d'un patient âgé de 52 ans, artéritique, multi-opérés, admis pour infection du scarpa droit sur un pontage fémoro-fémoral prothétique perméable, le patient a eu une explantation de ce pontage et une revascularisation par un pontage périnéal sous-scrotal veineux loin du site infectieux; l’évolution a été excellente et le pontage est encore perméable après deux ans de suivi. Le pontage fémoro-fémoral périnéal est une procédure exceptionnellement réalisée, mais qui peut constituer une vraie option thérapeutique de revascularisation chez les patients avec une infection du scarpa.

Gluteopopliteal bypass for a compromised groin

Extra-anatomic arterial reconstruction is indicated in patients with a compromised groin. Surgical options include obturator or transosseous bypass. We present a case of a patient with a necrotic radiation ulcer in the groin treated with a gluteopopliteal bypass.

Experience with new techniques for extraanatomic arterial reconstruction of the lower limb

The aim of this report is to present our experience with new techniques for extraanatomic lower limb arterial reconstruction. Two techniques are described here of construction of an extraanatomical bypass for lower limb revascularization either through the wing of the iliac bone or underneath the iliopsoas fascia through the muscular lacuna close to the anterior superior spine of the iliac crest. Both techniques are recommended for the treatment of a severely injured groin, such as in patients with pelvic malignancy and/or an acute groin bleeding due to postirradiation femoral artery erosion or an infected femoropopliteal bypass graft with severe upper medial thigh sepsis. These techniques were used in nine patients (five with malignancy and four with an infected femoropopliteal bypass graft). Our results showed that the transosseous route through the wing of the iliac bone or underneath the iliopsoas fascia through the muscular lacuna may be considered effective alternate routes for lower limb arterial extraanatomic reconstruction when the common femoral cannot be used for arterial inflow.

Use of descending thoracic aorta for lower limb revascularisation

From November 1984 to May 1991, descending thoracic aorta to femoral artery bypass was used to revascularise 51 lower limbs in 27 patients. There were 25 men and 2 women with a mean age of 60.2 years. There were four primary indications because of inability to use the abdominal aorta, and 23 secondary indications for late failure of a previous lower limb revascularisation: two aorto-prosthetic false aneurysms, nine infected aorto-bifemoral bypasses and 12 occluded grafts. Three deaths and one paraplegia occurred during the postoperative period, and three prosthetic occlusions and one popliteal embolism were successfully treated. During follow up (6-72 months) five deaths and three graft occlusions were observed; at 5 years, the cumulative life expectancy was 61.8 +/- 26.8%, and the cumulative secondary graft patency was 72.6 +/- 24.7%. One prosthetic infection and one ureteric fistula occurred and both were successfully treated. Thoracic aorta to femoral artery bypass is a simple extra-anatomic technique which can be used in cases of failure of a previous aorta to lower limb reconstruction. The haemodynamic results are good, and late results are better than axillo-femoral or bifemoral bypass.

Arterial infection following renal transplantation: successful management using transperineal femorofemoral crossover graft

Infection of a vascular prosthesis or an arterial receptor site is one of the most challenging situations for the vascular surgeon. In some instances the standard extraanatomic routes to bypass infected areas cannot be used. Two cases of arterial infection following renal transplantation are presented. An infrascrotal perineal approach for a femorofemoral bypass was used to achieve revascularization of a threatened limb.