Document Detail

Femoral vein obturator bypass revascularization in groin infectious bleeding: two case reports and review of the literature.
Jump to Full Text
MedLine Citation:
PMID:  23506237     Owner:  NLM     Status:  PubMed-not-MEDLINE    
INTRODUCTION: Groin infections resulting in arterial bleeding due to bacterial vessel destruction are a severe challenge in vascular surgery. Patients with them most often present as emergencies and therefore need individualized reconstruction solutions.
CASE PRESENTATION: Case 1 is a 67-year-old man with infectious bleeding after an autologous reconstruction of the femoral bifurcation with greater saphenous vein due to infection of a bovine pericard patch after thrombendarterectomy. Case 2 is a 35-year-old male drug addict and had severe femoral bleeding and infection after repeated intravenous and intra-arterial substance abuse. Both patients were treated with an autologous obturator bypass of the superficial femoral vein. We review the current literature and highlight our therapeutic concept of this clinical entity.
CONCLUSIONS: Treatment should include systemic antibiotic medication, surgical control of the infectious site, revascularization and soft tissue repair. An extra-anatomical obturator bypass with autologous superficial femoral vein should be considered as the safest revascularization procedure in infections caused by highly pathogenic bacteria.
Albert Busch; Udo Lorenz; George Christian Tiurbe; Christoph Bühler; Richard Kellersmann
Related Documents :
17643207 - Bilateral chylothoraces without chyle leakage after left-sided neck dissection for thyr...
15667687 - Penetrating injury of parotid gland and external auditory canal: a unique combination.
20872937 - Iodide mumps: sonographic appearance.
8165547 - Complete traumatic transection of the thyroid gland.
7371477 - Diffuse leiomyomatosis of the esophagus.
25133197 - Clinical, laboratory, and therapeutic analyses of 21 patients with neonatal thrombosis ...
Publication Detail:
Type:  Journal Article     Date:  2013-03-18
Journal Detail:
Title:  Journal of medical case reports     Volume:  7     ISSN:  1752-1947     ISO Abbreviation:  J Med Case Rep     Publication Date:  2013  
Date Detail:
Created Date:  2013-03-27     Completed Date:  2013-03-28     Revised Date:  2014-07-14    
Medline Journal Info:
Nlm Unique ID:  101293382     Medline TA:  J Med Case Rep     Country:  England    
Other Details:
Languages:  eng     Pagination:  75     Citation Subset:  -    
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): J Med Case Rep
Journal ID (iso-abbrev): J Med Case Rep
ISSN: 1752-1947
Publisher: BioMed Central
Article Information
Download PDF
Copyright ©2013 Busch et al.; licensee BioMed Central Ltd.
Received Day: 27 Month: 6 Year: 2012
Accepted Day: 24 Month: 1 Year: 2013
collection publication date: Year: 2013
Electronic publication date: Day: 18 Month: 3 Year: 2013
Volume: 7First Page: 75 Last Page: 75
PubMed Id: 23506237
ID: 3607977
Publisher Id: 1752-1947-7-75
DOI: 10.1186/1752-1947-7-75

Femoral vein obturator bypass revascularization in groin infectious bleeding: two case reports and review of the literature
Albert Busch1 Email:
Udo Lorenz1 Email:
George Christian Tiurbe1 Email:
Christoph Bühler1 Email:
Richard Kellersmann1 Email:
1Department of General, Visceral, Vascular and Paediatric Surgery University Clinic of Würzburg, Oberdürrbacher Strasse 6, Würzburg, D-97080, Germany


Severe groin infections with inguinal blood vessel destruction may be caused by intravenous substance abuse, radiation scars, transfemoral interventions and, most commonly, infection of prosthetic vascular implants (incidence 2% to 18%) [1-4]. Complications include life-threatening bleeding, acute ischemia, septic embolization and systemic sepsis. Finding the appropriate strategy for each patient remains an individual challenge.

Case presentation
Case 1

A 67-year-old Caucasian man was admitted to our institution with infectious bleeding in the right groin and lower limb ischemia 4 months after a prolonged hospitalization for common femoral artery thrombendarterectomy with a bovine pericard patch plasty and successful antibiotic treatment due to postoperative methicillin-resistant Staphylococcus aureus (MRSA) superinfection of an inguinal lymphatic fistula. For surgical control of bleeding, orthotopic revascularization with iliacofemoral and iliacoprofundal greater saphenous vein interposition and resection of the xenogenic patch material was performed, accompanied by systemic MRSA-specific antibiotic treatment. Three weeks later rebleeding occurred due to an infectious arterial pseudoaneurysm. Intra-operative findings revealed complete erosion of the profundal venous graft anastomosis (Figure 1A).

Case 2

A 35-year-old Caucasian man with extensive groin infection due to repeated drug abuse via the femoral vessels was transferred to our hospital 1 day after emergency implantation of an iliacofemoral and iliacoprofundal polytetrafluoroethylene prosthesis due to infectious bleeding together with rhabdomyolysis and sepsis with liver and kidney failure (Figure 1C). Massive gangrenous destruction of the femoral vessels and surrounding tissue were found intra-operatively, pending sufficient coverage of an orthotopic revascularization (Figure 2A). Group B Streptococcus was identified.

An obturator bypass using the ipsilateral superficial femoral vein to bypass the infected area extra-anatomically from the common iliac artery to the distal femoral artery was performed in both cases (Figures  2A and 2B). Venous graft was harvested from the non-infectious part of the thigh to the venous confluence. This procedure was accompanied by systemic antibiotic therapy, then by local debridements and finally by mesh graft augmentation. Physical therapy and 30mg enoxaparin daily were administered from day 1 after the operation. The patients were dismissed in good health and able to walk with regression of initial lymphatic swelling. Both bypasses remained patent during follow-up at 32 and 12 months in cases 1 and 2, respectively (Figures  1B and 1D). Venous function was not hindered clinically, with normal thigh circumference.


Though challenging, individual primary revascularization procedures, especially in young patients, should be considered the first treatment option because of high amputation rates after double or triple ligation (up to 27%) or severe claudication [4-7]. Without complete graft removal, reinfection occurs in about one-third of cases [8]. Insufficient soft-tissue coverage at the infection site weighs in favor of an extra-anatomic bypass configuration.

The obturator bypass, with primary patency rates of up to 76% after 2 years, has proven to be feasible in a few small clinical series with a considerable risk of late prosthetic graft infection remaining [1,3,4,9-11]. Therefore, evidence is increasing for the superiority of autologous revascularization with femoral veins to allograft, xenograft or synthetic materials, as well as greater saphenous vein (complete erosion despite antibiotic therapy in case 1) in terms of infection resistance, patency rates and availability [12-15].

To the best of our best knowledge, investigators of only one clinical series have reported the use of obturator bypass fashioned from autologous superficial femoral vein at infection sites [16]. We therefore want to highlight in our case presentations its potential benefits in vascular groin infections, with a crucial focus on the underlying bacteriology, such as MRSA and Group B Streptococcus in this report. With proven susceptibility of several native and prosthetic materials to MRSA and rising clinical incidence, femoral vein obturator bypass is the safest revascularization procedure with the best long-term results [17].


The extra-anatomic obturator bypass with femoral vein is a safe and feasible revascularization procedure in patients with severe groin infections and highly pathogenic bacteria such as MRSA, Pseudomonas aeruginosa and Group B Streptococcus. It should be considered the primary treatment option by vascular surgeons confronted with this problem, especially in young patients.


Written informed consent was obtained from the patients for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interests and did not receive any payment from industrial partners.

Authors’ contributions

RK, CB, CT and AB performed surgery on the patients and were responsible for postoperative intensive medicine care. UL performed vascular graft infection studies in mice and was a major contributor in writing the manuscript. All authors read and approved the final manuscript.


This publication was funded by the German Research Foundation (DFG) and the University of Wuerzburg in the funding programme Open Access Publishing.

Matoussevitch V,Aleksic M,Gawenda M,Brunkwall J,Primary extraanatomical revascularization for groin infections in drug addictsVasaYear: 20073621021410.1024/0301-1526.36.3.21018019279
Zetrenne E,McIntosh BC,McRae MH,Gusberg R,Evans GR,Narayan D,Prosthetic vascular graft infection: a multi-center review of surgical managementYale J Biol MedYear: 20078011312118299723
Meyer T,Schweiger H,Lang W,Extraanatomic bypass in the treatment of prosthetic vascular graft infection manifesting in the groinVasaYear: 19992828328810.1024/0301-1526.28.4.28310611847
Engin C,Posacioglu H,Ayik F,Apaydin AZ,Management of vascular infection in the groinTex Heart Inst JYear: 20053252953416429897
Scheuerlein H,Ruff S,Haage P,Zirngibl H,Fraunhofer S,Settmacher U,Groin abscesses and vascular catastrophes in intravenous drug users: strategy and results [in German]Zentralbl ChirYear: 2008133556010.1055/s-2008-100465818278704
Naqi SA,Khan HM,Akhtar S,Shah TA,Femoral pseudoaneurysm in drug addicts: excision without revascularization is a viable optionEur J Vasc Endovasc SurgYear: 20063158558710.1016/j.ejvs.2005.12.01116466941
Georgiadis GS,Lazarides MK,Polychronidis A,Simopoulos C,Surgical treatment of femoral artery infected false aneurysms in drug abusersANZ J SurgYear: 2005751005101010.1111/j.1445-2197.2005.03578.x16336398
Mayer D,Hasse B,Koelliker J,Enzler M,Veith FJ,Rancic Z,Lachat M,Long-term results of vascular graft and artery preserving treatment with negative pressure wound therapy in Szilagyi grade III infections justify a paradigm shiftAnn SurgYear: 201125475475910.1097/SLA.0b013e318236586421997817
Ferreira U,Reis LO,Ikari LY,da Silva W Jr,Matheus WE,Denardi F,Stopiglia RM,Menezes FH,Extraanatomical transobturator bypass graft for femoral artery involvement by metastatic carcinoma of the penis: report of five patientsWorld J UrolYear: 20082648749110.1007/s00345-008-0282-z18581120
Patel A,Taylor SM,Langan EM 3rd,Snyder BA,Cull DL,Sullivan TM,Youkey JR,Gray BH,Carsten CG,Obturator bypass: a classic approach for the treatment of contemporary groin infectionAm SurgYear: 20026865365812206597
Sautner T,Niederle B,Herbst F,Kretschmer G,Polterauer P,Rendl KH,Prenner K,The value of obturator canal bypass: a reviewArch SurgYear: 199412971872210.1001/archsurg.1994.014203100500088024451
Nevelsteen A,Lacroix H,Suy R,Autogenous reconstruction with the lower extremity deep veins: an alternative treatment of prosthetic infection after reconstructive surgery for aortoiliac diseaseJ Vasc SurgYear: 19952212913410.1016/S0741-5214(95)70106-07637111
Schulman ML,Badhey MR,Yatco R,Pillari G,A saphenous alternative: preferential use of superficial femoral and popliteal veins as femoropopliteal bypass graftsAm J SurgYear: 198615223123710.1016/0002-9610(86)90248-53740362
Biró G,Szeberin Z,Nemes A,Acsády G,Cryopreserved homograft and autologous deep vein replacement for infrarenal aorto and iliaco-femoral graft infection: early and late resultsJ Cardiovasc Surg (Torino)Year: 201152169176
Lorenz U,Schafer T,Ohlsen K,Tiurbe GC,Buhler C,Germer CT,Kellersmann R,In vivo detection of Staphylococcus aureus in biofilm on vascular prostheses using non-invasive biophotonic imagingEur J Vasc Endovasc SurgYear: 201141687510.1016/j.ejvs.2010.09.00720943422
Benjamin ME,Cohn EJ Jr,Purtill WA,Hanna DJ,Lilly MP,Flinn WR,Arterial reconstruction with deep leg veins for the treatment of mycotic aneurysmsJ Vasc SurgYear: 1999301004101510.1016/S0741-5214(99)70038-810587384
Murphy GJ,Pararajasingam R,Nasim A,Dennis MJ,Sayers RD,Methicillin-resistant Staphylococcus aureus infection in vascular surgical patientsAnn R Coll Surg EnglYear: 20018315816311432131


[Figure ID: F1]
Figure 1 

(A) Computed tomography scan of case 1 obtained after rebleeding due to septic pseudoaneurysm showing liquid, putrid formation (asterisk) with arterial extravasation caused by erosion of the distal anastomosis of the greater saphenous vein interposition and extensive perifocal soft-tissue edema in the right upper thigh. (B) Magnetic resonance angiogram of the obturator bypass in case 1 nearly 3 years after bypass surgery showing bypass perfusion free of stenosis (arrow). Case 2 (C) Computed tomography scan of case 2 at time of admission showing swelling, subcutaneous purulent formation and perifocal edema (asterisk). (D) Magnetic resonance angiogram obtained 3 months after surgery in case 2 showing the obturator bypass with retrograde perfusion of the profundal femoral artery by additional end-to-end anastomosis with proximal superficial femoral artery (arrow).

[Figure ID: F2]
Figure 2 

Intra-operative images. (A) The intraoperative site after radical debridement and the distal anastomosis of the implanted bypass (arrow) with gross incisions opening the whole upper thigh. (B) Suprapubic incision showing the proximal anastomosis before leaving the pelvic region through the obturator foramen.

Article Categories:
  • Case Report

Keywords: Obturator bypass, Groin infection, Autologous, Extra-anatomical, Femoral vein.

Previous Document:  Full-Range Intracellular pH Sensing by an AIE-Active Two-Channel Ratiometric Fluorogen.
Next Document:  Extensive drug resistance in HIV-infected Cambodian children who are undetected as failing first-lin...