Groin infection is a common and troublesome complication of vascular procedures, open and endovascular. In the setting of lower limb revascularization, wound and arterial infection hinder the usual inguinal approach. In this case, obturator bypass is usually the first line approach. Rarely reported, trans-iliac bypass tunnelling is a useful and valid approach that allows for adequate revascularization with acceptable patency rates in no-option patients.

The case report includes gathered information from electronic medical records, surgical reports and the picture archiving system.

We report a 44-year-old women with a past history of severe and complex abdomino-pelvic trauma after car collision with associated pelvic fracture in 2000. The patient required perianal and sphincter reconstruction, and a derivative colostomy. Sphincter reconstruction comprised a dynamic graciloplasty and electric stimulation using implantable stimulator in a subcutaneous right iliac pouch. In December 2021 she suffered a right ischemic stroke and was submitted to thrombectomy, recovering completely. A right femoral 8F access was used and percutaneously closed using Angio-Seal™. Two weeks later she presented in the ER complaining of a groin pulsatile hematoma with a previous self-limited bleeding episode. Initial assessment additionally revealed an associated groin infection with surrounding cellulitis. Doppler ultrasound exposed a large common femoral artery pseudoaneurysm and diffused hematoma. CT angiography confirmed a 50mm pseudoaneurysm with a 2mm neck as well as increased fat tissue densification with no individualized collections. Analytical revealed moderate systemic inflammatory response and Staphylococcus aureus septicaemia. Intraoperative findings included a large organized pseudoaneurysm capsule, tissue infection and associated cellulitis. CFA's anterior wall was destroyed and presented a 5mm defect. Angioplasty of a 40mm arterial segment was performed using ipsilateral great saphenous vein (GSV) with a good result. The electrodes lied just lateral to the CFA. Wound was left for secondary closure using negative pressure wound therapy (NPWT), with initial favourable results. One month later the patient presented in the ER complaining of inguinal bleeding and relapsed inflammatory signs. CT angiography exposed a new pseudoaneurysm arising from the previous reconstruction. Treatment comprised an external iliac to superficial femoral artery bypass using spliced femoral veins (unsuitable GSVs). A drill was used to perform a 20mm hole in the iliac wing allowing trans-iliac graft tunnelling. An obturator bypass was opted out due to previous pelvic fracture with associated fibrosis and neovascularization. The inguinal approach was then debrided and the femoral bifurcation ligated. The electrodes and its stimulator were removed due to its role in the perpetuation of the infection. Postoperative period was unremarkable. Faecal continence was maintained despite stimulator removal and inguinal wound healed within 35 days using NPWT. Elastic compressive stockings allowed good oedema control. The patient was maintained under anticoagulation.

In situ reconstruction for inguinal infection has limitations, especially when perpetuation of infection occurs. Historically, extra-anatomical revascularization using obturator bypass is used. Trans-iliac bypass can be used for patients with inguinal infections in whom obturator bypass is not possible. Its patency rates are comparable to the later, without increased morbidity.

Enzmann F, Nierlich P, Eder S, Aspalter M, Dabernig W, Aschacher T et al. Trans-Iliac Bypass Grafting for Vascular Groin Complications. European Journal of Vascular and Endovascular Surgery. 2019;58(6):930-935.