The Debatable Choice of Iliac Inflow Source for Redo Femoropopliteal and Infrapopliteal Bypass

Redo area region operation is associated with a significant morbidity such as neurovascular injury, infection, and lymphorrhea. The traditional management of occluded femoropopliteal grafts often includes redissection of a scarred groin to obtain adequate inflow via the common femoral artery. These procedures are more technically demanding and require more expertise and judgment than the primary operation. We describe a case of using the ipsilateral iliac branch prosthesis of aortobifemoral bypass as inflow for iliac-peroneal bypass, avoiding the previous groin incisions, to minimize the local complications related to a redo groin dissection and to decrease the operative time required to obtain an adequate inflow source. An 86-year-old man was referred to our hospital with severe pain in the right lower extremity one day before the present admission. He underwent aortobifemoral bypass for Leriché syndrome, in our department, 10 years before the present admission. Eight and 9 years later, a femoral popliteal suprageniculate bypass and jump to deep femoral artery bypass (when femoropopliteal bypass was occluded) were performed with 6-mm polytetrafluoroethylene grafts, both in some other institution. The patient's right foot was colder than the left, and he had some difficulty with movement. Absence of signal Doppler continous wave at right tibial vessels was recorded (category IIA of Rutherford classification for acute limb ischemia). Computed tomography (CT) confirmed the following duplex ultrasound (US) findings: occlusion of the femoral graft and popliteal artery below the knee and preocclusive stenosis of deep femoral artery with patency of aortobifemoral bypass and peroneal artery. Taking into consideration the multiple groin scars and the occlusion of superficial femoral and popliteal arteries and preocclusive lesion of deep femoral artery, we decided to perform a sequential composite and extra anatomical bypass from the right iliac prosthesis to the peroneal artery, with graft tunnellization through the lateral groin subfascial layer. The proximal component of the graft was made with a 6-mm Dacron prosthesis routed through a suprasartorial tunnel from iliac prosthesis to the proximal great saphenous vein. Proximal anastomosis was performed in a conventional side-to-end fashion. A tunnel was created between the abdominal flank incision and the median prosthesis-vein anastomosis of the bypass under inguinal ligament laterally with respect to femoral ves