# Obturator Foramen Bypass With Fluoroscopic Guidance for Recurrent Femoral Prosthetic Bypass Occlusions: A Case Report

## TL;DR

This case report describes a successful surgical bypass through the obturator foramen to treat a patient with multiple blocked femoral bypasses and chronic limb-threatening ischemia.

## Contribution

The paper presents a novel application of obturator foramen bypass using fluoroscopic guidance to address femoral crowding and hip flexion-induced compression.

## Key findings

- Obturator foramen bypass was successfully performed under live fluoroscopic guidance using Artis zeego.
- The graft remained patent for 12 months post-surgery, with no complications.
- The procedure avoided the risks of groin infection and femoral compression during hip flexion.

## Abstract

Repeated and additional prosthetic bypass to the femoral artery causes femoral crowding and adhesion and increases the risk of bypass infection. The femoral crowding may cause the stenosis of native and prosthetic bypass during hip flexion. An obturator foramen bypass is a bypass from a particular branch of the abdominal aorta to the lower limb artery to circumvent groin infection. This procedure is particularly effective in treating infected femoral prosthetic bypasses and mycotic femoral artery aneurysms; however, the bypass is routed through a narrow obturator foramen, which requires advanced technical skills.

A 57-year-old Japanese man with a history of a coronary stent occlusion and a terminal aorta-left common femoral artery (CFA) prosthetic bypass occlusion underwent a right external iliac artery (EIA)-left superficial femoral artery (SFA) crossover prosthetic bypass. At the age of 61 years, the patient presented with pain in the left first toe with purulent discharge and noticed that the toe turned purple when his left hip joint was flexed during soaking in the bathtub. Contrast-enhanced computed tomography revealed occlusion of the right EIA-left SFA crossover prosthetic bypass and left narrow and shaggy CFA and SFA. Compression of the left CFA between the two occluded prosthetic bypasses and the caput femoris during hip flexion was considered to limit the blood flow to the lower limb, leading to chronic limb-threatening ischemia (CLTI). Those multiple femoral prosthetic bypasses had resulted in left femoral crowding, raising concerns that a new bypass to the left CFA might be compromised by the dynamic femoral compression during hip flexion. Therefore, an alternative bypass route was necessary. We successfully performed a 25-cm thrombectomy of the left femoral artery, followed by a right common iliac artery (CIA)-left SFA crossover prosthetic bypass through the left obturator foramen under live fluoroscopic guidance using Artis zeego (Siemens Healthineers, Erlangen, Germany). The postoperative course was uneventful. The graft remained patent over 12 months.

Obturator foramen bypass may be considered an option not only in avoiding inguinal infections but also in addressing femoral crowding and compression caused by hip flexion. Penetrating the obturator foramen should be performed at the center or lower position. Preoperative vascular assessment of the foramen ovale on CT is also important. The procedure can be safely performed under live fluoroscopic guidance.