Aortic-tibial transiliac wing extra-anatomic bypass with distal fistula for treatment of an infected deep femoral pseudoaneurysm.

Abstract

Transiliac wing bypass has been reported to be a viable extra-anatomic alternative technique for patients presenting with a history of groin infection or irradiation.1Enzmann F.K. Nierlich P. Eder S.K. Aspalter M. Dabernig W. Aschacher T. et al.Trans-iliac bypass grafting for vascular groin complications.Eur J Vasc Endovasc Surg. 2019; 58: 930-935Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Of the 32 reported cases, only two patients had undergone transiliac aortic–tibial or iliotibial bypass.2Sekanina G. Lemminger F. Bruecher D. Iliaco-crural bypass through a borehole in the iliac fossa as extra-anatomic vascular bypass in infected inguinal canal and posterior aspect of the knee.Chirurg. 1995; 66: 142-145PubMed Google Scholar,3Heldenberg E. Lorber J. Cheyn D. Bass A. Transiliac wing alternate route bypass for infected groin vascular graft.J Vasc Surg. 2014; 60: 504-505Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar We report the case of a 72-year-old man with a complex history of multiple lower limb revascularizations, who had been admitted for a deep femoral infected anastomotic pseudoaneurysm (A) and left chronic limb threatening ischemia. Computed tomography showed chronic occlusions at the femoropopliteal level, with a previous thrombosed obturator canal bypass. The only patent lower leg artery was the posterior tibial artery (PTA) from its mid-third to the foot.A transiliac wing aortic–tibial prosthetic bypass was performed through a pararectal retroperitoneal approach (B/Cover). The infrarenal aorta and common iliac arteries were cross-clamped before implanting an 8-mm expanded polytetrafluoroethylene graft soaked in rifampicin at the terminal aorta level. It was tunneled into the retroperitoneal space, over the psoas muscle. A U-shape osteotomy was performed at the anterior left iliac wing border through a second lateral incision to guide the bypass. Another incision was made at the lateral side of the thigh to guide the graft route between the femoral condyles. It was associated with a distal arteriovenous bypass between the PTA and a fibular vein (C), before the distal anastomosis of the aortic–tibial bypass, to partially deviate the aortic blood flow from the PTA into the venous circulation.The second part of the procedure consisted of deep femoral pseudoaneurysm repair. It was developed at the distal anastomosis level of the thrombosed obturator canal bypass, which was removed to the obturator canal during the same procedure. The deep femoral artery was then ligated with 5-0 polypropylene suture. Transiliac wing bypass has been reported to be a viable extra-anatomic alternative technique for patients presenting with a history of groin infection or irradiation.1Enzmann F.K. Nierlich P. Eder S.K. Aspalter M. Dabernig W. Aschacher T. et al.Trans-iliac bypass grafting for vascular groin complications.Eur J Vasc Endovasc Surg. 2019; 58: 930-935Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Of the 32 reported cases, only two patients had undergone transiliac aortic–tibial or iliotibial bypass.2Sekanina G. Lemminger F. Bruecher D. Iliaco-crural bypass through a borehole in the iliac fossa as extra-anatomic vascular bypass in infected inguinal canal and posterior aspect of the knee.Chirurg. 1995; 66: 142-145PubMed Google Scholar,3Heldenberg E. Lorber J. Cheyn D. Bass A. Transiliac wing alternate route bypass for infected groin vascular graft.J Vasc Surg. 2014; 60: 504-505Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar We report the case of a 72-year-old man with a complex history of multiple lower limb revascularizations, who had been admitted for a deep femoral infected anastomotic pseudoaneurysm (A) and left chronic limb threatening ischemia. Computed tomography showed chronic occlusions at the femoropopliteal level, with a previous thrombosed obturator canal bypass. The only patent lower leg artery was the posterior tibial artery (PTA) from its mid-third to the foot. A transiliac wing aortic–tibial prosthetic bypass was performed through a pararectal retroperitoneal approach (B/Cover). The infrarenal aorta and common iliac arteries were cross-clamped before implanting an 8-mm expanded polytetrafluoroethylene graft soaked in rifampicin at the terminal aorta level. It was tunneled into the retroperitoneal space, over the psoas muscle. A U-shape osteotomy was performed at the anterior left iliac wing border through a second lateral incision to guide the bypass. Another incision was made at the lateral side of the thigh to guide the graft route between the femoral condyles. It was associated with a distal arteriovenous bypass between the PTA and a fibular vein (C), before the distal anastomosis of the aortic–tibial bypass, to partially deviate the aortic blood flow from the PTA into the venous circulation. The second part of the procedure consisted of deep femoral pseudoaneurysm repair. It was developed at the distal anastomosis level of the thrombosed obturator canal bypass, which was removed to the obturator canal during the same procedure. The deep femoral artery was then ligated with 5-0 polypropylene suture. Appendix