Objective: Management of limb ischemia in the setting of malignancy with history of resection and/or radiation presents a unique challenge. Radiation arteritis contributing to limb ischemia may not respond to endovascular intervention. Furthermore, significant tissue scarring from extensive resection and/or radiation can increase the risk of complications with open intervention and limit revascularization options. Utilization of an axillary to popliteal artery bypass using a lateral approach to the popliteal artery has been described as a reasonable alternative in these challenging cases.
Case report: The patient is a 68-year-old male with history of liposarcoma of the left groin, scrotum, and medial thigh for which he underwent multiple resections, flap reconstruction, and skin graft. He had a recurrence 2 years later and underwent repeat resection, placement of brachytherapy catheters, vertical rectus abdominal flap, and external beam radiation. He now presents with Rutherford 2B acute limb ischemia with associated left foot drop. Computed tomography angiography was performed and revealed an occluded left common femoral artery stent, proximal left superficial and deep femoral artery occlusion, and thrombosis of the left femoral vein. An attempt was made at endovascular recanalization without success. He subsequently underwent left axillary-to-lateral above knee popliteal artery bypass with a 6 mm ringed polytetrafluoroethylene graft, tibial thrombectomy, and 4 compartment fasciotomy.
Results: Post-operatively, his pain resolved. He continued to have left foot drop but recovered his ability to ambulate with a walker. He was ultimately discharged on post-operative day 11 to an inpatient rehabilitation facility on aspirin and apixaban.
Conclusion: Hostile groin secondary to infection, malignancy requiring resection/radiation presents a unique challenge for revascularization. When endovascular revascularization or obturator bypass are not feasible options, axillary-to-lateral above knee popliteal artery bypass is a described, feasible alternative approach to restore blood flow in this challenging patient population.
Keywords: axillary artery; extra-anatomic; lateral; obturator bypass; popliteal artery; radiation arteritis; sarcoma.