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Crossover Ilio-Popliteal Obturator Bypass in the Setting of Previous Aortobifemoral Bypass and Complicated Groin Infection
Alexandra Sasha Laykova, Andrew Kimball
Corewell Health West, Grand Rapids, MI
INTRODUCTION: Graft infection continues to be one of the most feared complications in vascular surgery. Revascularization options are particularly challenging in slender patients with limited extra-anatomical tunneling options and prior prosthetic in a field that tunnels underneath the inguinal ligament. An obturator bypass provides a means for restoring blood flow in cases of deep groin infection, though it is technically demanding due to limited visualization and reliance on palpation for graft passage. Crossover obturator bypass is performed even less frequently given its complexity. Selection of an appropriate revascularization strategy for patients with graft infection must therefore be highly individualized in patients with limited extra-anatomical options.
METHODS: This case demonstrates a complex right to left crossover ilio-popliteal obturator bypass in the setting of a groin infection with a prior aortobifemoral bypass (ABF).
RESULTS: A 75 y.o. female with a history of aortoiliac occlusive disease and prior ABF performed 7 years prior presented with lifestyle-limiting left lower extremity claudication. Imaging demonstrated stenosis of the left common femoral artery (CFA) at the distal aorto-femoral anastomosis, with an ankle-brachial index (ABI) of 0.66. The patient subsequently underwent elective revision of the left distal aorto-femoral bypass with left common femoral endarterectomy and bovine patch angioplasty. Her post operative course was complicated by left groin hemorrhage, requiring redo patch angioplasty, sartorius muscle flap coverage and negative pressure wound therapy followed by delayed primary closure. She was subsequently discharged in stable condition to rehab. One month later, the patient presented to the emergency department with active left groin hemorrhage. She was brought to the operating room for left superficial femoral artery cutdown and stent placement of the left CFA for hemorrhage control. Following this damage-control procedure, she underwent left groin irrigation and debridement, which revealed a grossly infected bovine patch. CT imaging demonstrated no evidence of fluid collection or infection around the remaining ABF, which appeared well incorporated proximally. Given the localized infection and preserved proximal graft integrity, definitive management included a right-to-left crossover ilio-popliteal obturator bypass with ringed PTFE, along with explantation of the infected patch and stent, and ligation of all distal arterial segments including the external iliac, superficial femoral, profunda femoris, and the affected left aorto-femoral limb. Post operatively the groin infection was managed with antibiotic-impregnated beads, intravenous antibiotics and continued negative pressure wound therapy. The patient recovered well, with complete wound healing, resolution of claudication symptoms, and improvement of her ABI to 0.99 at follow-up.
CONCLUSIONS: This case highlights the utility of crossover ilio-popliteal obturator bypass as a viable revascularization strategy in the setting of a complex groin infection in a slender patient with limited extra-anatomical tunneling options. Despite its technical challenges, this approach was successfully performed in a patient with prior ABF reconstruction and localized graft involvement. A combination of graft explanation, targeted revascularization, and aggressive infection management was essential in achieving a favorable clinical and functional outcome.
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