Techniques for Obturator Bypass - VascularWeb

SVS Postgraduate EducationCourseTechnical Aspects of Complex OpenVascular Surgery:Obturator BypassJoseph S. Giglia, MDMay 29, 2013

• Nothing to discloseDisclosures

Objective• To describe how to perform an obturatorbypass

Outline• Anatomy• Technique• Cases• Pitfalls

History• Shaw RS and Baue AE– Management of sepsiscomplicating arterialreconstructive surgery Surgery1963; 53:75-86• Veith FJ, Hartsuck JM and Crane C– Management of aortoiliacreconstruction complicated bysepsis and hemorrhage NEJM1964; 270:

Anatomy

Anatomy

Preoperative Preparation• Resuscitation• Antibiotics• Imaging• Operative Planning

Technique• Isolate the infection• Perform the exposure– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate the clean incisions• Debride the infection

“Subtle”• Isolate the infection• Perform the exposure– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Not so subtle• Isolate the infection• Perform the exposure– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Not so subtle• Isolate the infection• Perform the exposure– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Technique• Isolate the infection• Perform the exposure– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Technique• Isolate the infection• Perform the exposure– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Technique• Aorta• Iliac– Common– External– Ipsilateral orcontralateral• Grafts• Isolate the infection• Perform the exposure– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Technique• Isolate the infection• Expose the vessels– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Technique• Profunda• Superficial femoral• Popliteal• Isolate the infection• Expose the vessels– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

TechniqueModified technique of obturator bypass infailed or infected grafts.W H Pearce, J B Ricco, J S Yao, W R Flinn, andJ J BerganAnn Surg. 1983 March; 197(3): 344–347• Isolate the infection• Expose the vessels– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Technique• Isolate the infection• Expose the vessels– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Technique• Isolate the infection• Expose the vessels– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Technique• Reinforced PTFE • Isolate the infection• Expose the vessels– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Technique• Isolate the infection• Expose the vessels– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Technique• Isolate the infection• Expose the vessels– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Technique• Attempt to maintainthe femoralbifurcation– Oversew the distalcommon femoral– Transpose thesuperficial femoral tothe profunda• Isolate the infection• Expose the vessels– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Clinical History-Case 1• 63 yo man• Aortobifemoral bypass– Left limb occlusion• Fem-fem bypass• Bilateral groin infections

Preoperative CT

Technique• Isolate the infection• Expose the vessels– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Technique• Isolate the infection• Expose the vessels– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Technique• Isolate the infection• Expose the vessels– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Technique• Isolate the infection• Expose the vessels– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Technique• Isolate the infection• Expose the vessels– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Technique• Isolate the infection• Expose the vessels– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Technique• Isolate the infection• Expose the vessels– Inflow– Outflow• Tunnel• Perform the bypass• Close and isolate theclean incisions• Debride the infection

Postoperative Imaging

Video not present

Video not present

Clinical History-Case 2• 55 yo man s/p left internal iliacembolization and EVAR• Left femoral infection and hemorrhage X 2• Transfer

Wishful Thinking

Expose the vessels- inflow

Expose the vessels- inflow

Perform the bypass

Proximal end of the obtuartorbypass

Obturator bypass deep in thepelvis

Femoral wound duringdebridement

Post Operative CTVideo not present

Post Operative CTVideo not present

• Pelvic IschemiaPitfalls

Pelvic Ischemia

Pelvic Ischemia

Pitfalls• Pelvic ischemia• Pelvic radiation

Summary• Obturator bypass is a useful operationwhen faced with common femoral arteryinfection• Interval pelvic ischemia is a potentialcomplication• It should be avoided if there has beenpelvic radiation

VASCULAR