In patients with previous multiple arterial reconstructions in the groin, prior history of graft infection, femoral artery infections in patients with intravenous drug abuse, and those with history of groin radiation pose technical challenges for arterial reconstruction in the groin. Management options in such cases include arterial reconstruction with axillo-popliteal bypass with prosthetic graft or autologous bypasses such as the use of femoral and popliteal veins. In such situations, an alter­native approach is to perform distal anastomosis to the mid- or distal SFA via lateral approach, or consideration of obturator bypass for arterial reconstruction.

Obturator bypass is considered in patients with unilateral graft limb infection sec­ondary to a previous aortobifemoral graft (ABF) reconstruction. Evaluation of CT imaging should conrm the absence of infection in the main body of the graft or involvement of the contralateral limb by the absence of periuid/gas collection to consider reconstruction using obturator bypass as an alternate to standard arterial reconstruction. At the time of intra-abdominal or retroperitoneal exploration, the main body of the graft should be well incorporated. The affected limb is transected, and opening is made in the anteromedial aspect of the obturator membrane by pal­pation of the pubis, and moving the nger laterally till the edge of the rm obturator membrane can be palpated (Figs.35.1 and 35.2). Metzenbaum scissors is used to incise the obturator membrane over the guidance of the nger. A blunt-tipped tun­neler such as Gore or Garrett tunneler is passed from the obturator fossa into the medial thigh anterior to the adductor longus muscle. Supercial femoral artery is exposed under the sartorius muscle in the midthigh, and distal anastomosis of an 8mm PTFE graft (interring) is performed to the mid- or distal supercial femoral artery. The distal anastomosis to the popliteal artery may need to be performed in patients with occlusion of SFA.The proximal graft anastomosis is performed prior to passage of the graft through the obturator tunnel in an end-to-end fashion with the previously placed limb which is divided ush at the body of the graft with 4-0 CV polypropylene suture [1]. After both anastomoses are completed, the patient is redraped, and retroperitoneal incision and the incision on the middle thigh are iso­lated, and groin incision is opened; all the prosthetic materials are removed, as well as excisional debridement of the tissues is performed. Common femoral artery is oversewn by a monolament suture such as 4-0 CV polypropylene.

Exposure of distal segment of the deep femoral artery is useful regardless of whether the artery is used as an outow vessel or serves as inow source. This expo­sure is useful in patients with prior multiple groin exposures, groin infection, or in patients with history of prior radiation. The skin incision is made along the medial border of sartorius (anteromedial approach) or lateral border of the sartorius which is preferable (anterolateral approach); once the dissection is done along the deeper plane, the sartorius muscle is retracted medially or laterally depending upon the selected approach (Fig.35.6). The dissection is done lateral to SFA and accompany­ing nerve between medial border of the adductor longus muscle (medially) and into the vastus medialis laterally. Profunda femoris (deep femoral artery) and its accom­panying vein can be visualized. Small vein tributaries crossing the deep femoral artery may require ligation and division to obtain satisfactory exposure of the deep femoral artery.