Obturator foramen grafts: the preferable alternate route?

Although the femoral canal is the standard entrance route for vascular grafts to the lower extremity, several situations may arise that preclude the use of this route. In these circumstances an alternate pathway for revascularization is required. Experience in our center with the use of obturator foramen grafts for revascularization of nine limbs in eight patients is reported and underscores the value of this pathway as an alternative route for limb revascularization. The obturator foramen was employed to circumvent an infected arterial prosthesis at the groin level in seven patients (eight limbs) from 12 days to 4.5 years after the initial vascular procedure. The organisms responsible for graft infection included Staphylococcus aureus, Enterobacter cloacae, and Bacteroides fragilis. The final patient required iliac to superficial femoral artery bypass via the obturator foramen to manage occlusion and autolysis of the femoral artery by a mycotic embolus containing beta-hemolytic Streptococcus. Graft material used for these remedial procedures, included saphenous vein (three), Gore-Tex (three), and Dacron (three). Revascularization was satisfactory in each case. Each groin infection healed. Two patients died of unrelated causes at 1.5 and 5 months after operation. The seven remaining grafts at risk (six patients) remained patent 12 months in each case. Four grafts were doing well at 18, 36, 50, and 52 months. Three grafts failed at 13, 19, and 28 months; one was revised successfully, one was re-done and failed again. Obturator foramen bypass grafting provides satisfactory and durable revascularization when an alternate route to the lower extremity is required.