Clinical Research

Secondary Extra-anatomic Infrainguinal

Bypass following Lower Limb Tumoral
Resection
L
eonore Freycon-Tardy, Doctor of General Surgery,
Dorian Verscheure, Doctor of Vascular Surgery,
Elie Fadel, Professor of Thoracic and Cardio-Vascular Surgery,
Sacha Mussot, Doctor of Thoracic and Cardio-Vascular Surgery,
Olaf Mercier, Professor of Thoracic and Cardio-Vascular Surgery,
Philippe Brenot, Doctor of Cardiovascular and Interventional Radiology,
Ryad Bourkaib, Doctor of Interventional Cardiology,
Dominique Fabre, Professor of Thoracic and Cardio-Vascular Surgery, and
Stephan Haulon, Professor of Vascular Surgery, Plessis-Robinson, France

Background: Soft tissue malignancy of lower limb can involve femoral triangle by direct tu-
moral invasion or secondary to ganglionic metastasis. Secondary arterial complications can
appear during follow-up after initial tumoral resection and local radiation therapy. The aim of
this study is to report our experience of secondary extra-anatomical lower limb revascularization
following lower limb oncological resection with femoral bifurcation involvement.
Methods: This is a retrospective monocentric study including patients who underwent extra-
anatomical iliopopliteal bypass, with a previous treated neoplasia involving homolateral femoral bifur-
cation. Proximal anastomosis was performed on the iliac artery, tunnelization was made through iliac
wing, and distal anastomosis was done on distal superficial femoral or popliteal artery.
Results: Five patients underwent extra-anatomic iliopopliteal bypass for oncological purpose
from 2008 to 2018 at our institution. Mean age at surgery time was 52 years (standard
deviation ¼ 19.3). Prosthetic graft was used in all cases. Primitive tumor involved Scarpa trian-
gle in 3 cases (soft tissue sarcomas) and ganglionic metastasis involved Scarpa triangle in 2
cases (epidermoid carcinoma). Clinical presentation was ischemic in 4 cases and hemorrhagic
in 1 case. One patient died during hospitalization. Of the 4 survivors, 3 patients had a patent
bypass at the end of follow-up (2 had bypass thrombectomy, 1 patient had major amputation).
Conclusions: Secondary iliopopliteal bypasses through the iliac wing following lower limb tu-
moral resection have acceptable results. It is a valid option for limb salvage especially after local
radiation therapy and tumoral resection. Multidisciplinary management is necessary to obtain
acceptable results and follow-up is mandatory.

Aortic Centre, H^opital Marie Lannelongue, Universit
e Paris Sud,

Plessis-Robinson, France.
Correspondence to: Dominique Fabre, Aortic Centre, H^opital Marie
Lannelongue, Universit
e Paris Sud, Plessis-Robinson, France; E-mail:
d.fabre@hml.fr
Ann Vasc Surg 2020; -: 1–4
https://doi.org/10.1016/j.avsg.2020.01.074
Ó 2020 Elsevier Inc. All rights reserved.
Manuscript received: December 6, 2019; manuscript accepted: January
12, 2020; published online: - - -
INTRODUCTION
Soft tissue malignancy of lower limb can involve
femoral triangle by direct tumoral invasion or sec-
ondary to ganglionic metastasis. Curative treatment
of those tumors usually request surgical in block
resection with possible additional local radiation
therapy,1 while ganglionic metastasis request surgi-
cal lymph nodes resection or radiation therapy.

1
2 Freycon-Tardy et al.
Involvement of vascular structures can request
arterial resection and in situ reconstruction.
Vascular complications can appear during follow-
up, with hemorrhagic or ischemic clinical presentation
due to radiation therapy effects.2 In situ revasculariza-
tion is recommended as the first-line treatment,
regrettably hostile groin contraindicate its achieve-
ment.3 Lower limb revascularization remains chal-
lenging in those cases. Extra-anatomical bypass is an
effective option to avoid tissue damages.
Only 31 trans-iliac bypasses are described in liter-
ature: some cases report and less than 10 studies
with no more than 8 patients included are re-
ported.4 The studies reporting cases of trans-iliac
bypass are often heterogenous and gather infectious
and oncological background. Indeed, the account-
able pathologies are uncommon, but clinical situa-
tion is serious and challenging for lower limb
preservation in those young patients.
The aim of this study is to report our experience of
secondary extra-anatomical lower limb revasculari-
zation following lower limb oncological resection.
METHODS
This is a retrospective monocentric study. Inclusion
criteria were patients who underwent extra-
anatomical iliopopliteal bypass, with a previous
neoplasia involving homolateral femoral bifurcation.
Patients who underwent iliopopliteal bypass for sep-
tic involvement of Scarpa triangle were excluded.
Following data were retrieved: patients’ demo-
graphics, presenting symptoms, modality of iliopopli-
teal bypass, short-term survival and complication
rate (first 30 postoperative days), long-term compli-
cations, survival, permeability, and amputation rates.
Permeability of extra-anatomical bypass was rated
on ultrasounddDoppler or computed tomography.
Operative Technique
Iliac artery was exposed through a standard extrap-
eritoneal lobotomy. Proximal anastomosis was
made on primitive or external iliac artery.
Tunneling through the iliac wing was performed
by an upper scallop or a bone fenestration using
an orthopedic drill.
A subcutaneous lateral run was used external to
the Scarpa triangle, then the superficial femoral ar-
tery or popliteal artery was reached threw a medio-
crural crossover.
Distal anastomosis was performed on popliteal ar-
tery or medio-crural superficial femoral artery. A
prosthetic graft was used as vascular substitute.
Annals of Vascular Surgery
RESULTS
Five patients underwent extra-anatomic iliopopli-
teal bypass for oncological purpose from 2008 to
2018 at our institution. Mean age at surgery time
was 52 years (standard deviation [SD] ¼ 19.3). Pros-
thetic graft was used in all cases.
All bypasses were performed during follow-up of
soft tissue lower limb malignancy for vascular
complication involving femoral bifurcation. All pa-
tients already had initial surgery involving femoral
Scarpa triangle area and/or radiation therapy
(Table I) in other institutions.
Oncological Medical History
Tumor histology was epidermoid carcinoma (2
cases) and soft tissue sarcomas: liposarcoma (1
case), mesenchymal tumor (1 case), and synovial
sarcoma (1 case) (Table I).
Primitive tumor involved Scarpa triangle in 3
cases (soft tissue sarcomas) and ganglionic metas-
tasis involved Scarpa triangle in 2 cases (epidermoid
carcinoma).
Vascular Presentation
Clinical presentation was ischemic in 4 cases (4 crit-
ical limb ischemia) and hemorrhagic in 1 case. In
the 4 ischemic patients, critical ischemia was sec-
ondary to native artery occlusion in 3 cases and sec-
ondary to a bypass occlusion in 1 case. This bypass
was performed for in situ arterial reconstruction
during previous tumoral resection. Those 4 pa-
tients had previous primitive tumor resection in 3
cases and Scarpa triangle lymphadenectomy in 1
case. Three of them had local radiation therapy.
The patient with hemorrhagic presentation
(Fig. 1) had a history of lower limb squamous cell
carcinoma with ganglionic inguinal metastasis
and only received Scarpa triangle radiation ther-
apy. In this case, femoral bifurcation was resected
with proximal and distal ligature, and lower limb
revascularization was performed using extra-
anatomical bypass.
Postoperative Course
Technical success was achieved in all patients.
Patient number I requested endovascular emboliza-
tion of an iliac collateral artery at day 7 for persistent
small bleeding following the ligation. Surgical rein-
tervention was not indicated regarding the surgical
hostility of the Scarpa triangle and endovascular
approach was chosen to complete the vascular
exclusion of the femoral bifurcation.
Volume -, - 2020 Secondary extra-anatomic infrainguinal bypass following lower limb tumoral resection 3

Table I. Patients’ oncological history

Patient
number Malignancy Scarpa triangle surgery Radiation therapy Clinical presentation Vascular involvement

I Lower limb squamous No Yes Hemorrhagic Common femoral

cell carcinoma with artery rupture
ganglionic inguinal
metastasis
II Lower limb squamous Lymphadenectomy Yes Critical ischemia Native femoropopliteal
cell carcinoma with occlusion
ganglionic inguinal
metastasis
III Scarpa triangle Tumoral resection Yes Critical ischemia Native femoropopliteal
mesenchymal tumor occlusion
with femoral
invasion
IV Thigh liposarcoma with Tumoral resection and Yes Critical ischemia Bypass thrombosis
Scarpa invasion in situ arterial
reconstruction
V Hip synovial sarcoma Tumoral resection No Critical ischemia Native femoropopliteal
occlusion

postoperative gangrene following revascularization.

He died postoperative day 12 despite emergent
transfemoral amputation.
There was no other complication related to the
procedure during postoperative course.

Follow-up
Of the 4 survivor, 3 patients had a patent bypass at
the end of follow-up (Table II). Two patients had
successful bypass thrombectomy, associated with
distal anastomosis repair (transluminal angioplasty
in 1 case and surgical refection in 1 case). Those 2
patients had uneventful postoperative course and
requested no amputation. One patient had major
amputation at postoperative year 2 secondary to
bypass occlusion. One patient had an uneventful
follow-up. We did not report specific complication
involving transiliac tunneling.
Mean follow-up was 42 months (SD ¼ 35.7).

Fig. 1. Scanographic reconstruction showing tumoral
involvement (red arrow) of the femoral bifurcation
responsible for spontaneous hemorrhage.
Patient number II died during hospitalization of
septic complication in a polymetastatic state. This
patient had lower limb large ulcer and developed
DISCUSSION
Limb sparing is an imperative concern during lower
limb neoplasia surgery.
Lower limb soft tissue malignancy resection re-
quests aggressive treatment by a multimodality
therapy. For high grade sarcoma, there is usually a
neoadjuvant chemotherapy followed by a surgical
resection with large margins. For other tumors, it
is surgical resection with a large excision with
or without adjunctive radiation therapy.1 Wide
4 Freycon-Tardy et al. Annals of Vascular Surgery

Table II. Short and long-term outcomes

Patient number J30 outcome Status at last follow-up

I Discharged Patent, uneventful

II Death Not applicable
III Discharged Patent, successful thrombectomy at postoperative year 3
IV Discharged Bypass occlusion and major amputation at postoperative year 2
V Discharged Patent, successful thrombectomy at postoperative year 6

margins (R0 resection) among the tumor are
mandatory.
Femoral vessels can be involved by the primitive
tumor or by ganglionic metastasis. In this case, it
also requests a local arterial reconstruction. Vessel
reconstruction could be necessary after an adjuvant
radiation therapy or in case of nodes metastasis. Local
arterial reconstruction must be performed during the
initial surgery when vascular structures are involved
by the tumoral process. In this case, in situ bypass
provides durable oncologic and patency results.3,5
Regarding femoral bifurcation, arteries request
reconstruction, while venous vessels can be ligated
with small consequences while local venous recon-
struction has high thrombose rate.
Endovascular approach for arterial reconstruction is
not a good option when a long arterial reconstruction
is requested especially when an extra-anatomical
route for revascularization is needed.
Nevertheless, endovascular embolization can be
used as an adjunctive procedure in hemorrhagic sit-
uations as we performed in 1 case.
In situ revascularization was not achievable for
our patients because of the inaccessibility of the
femoral triangle due to extensive compartmental
resection, sequelae of radiation therapy, or fibrosis
evolution, in this nonconcomitant revascularization.
Therefor an extra-anatomical bypass is justified.6
Iliopopliteal bypass through obturator foramen
was reported7,8 but is not applicable in this oncolog-
ical situation because of radiation therapy conse-
quences that improves the difficulty of dissecting
the inguinal area, even if it is only for tunneling.
Indeed, radiation therapy induces cutaneous burns
and sequels with a high risk of necrosis. A local
revascularization could lead to an infection or a
skin necrosis with a high risk of gangrene.
The groin after those treatments should be
avoided. Furthermore, in those particular oncolog-
ical cases, deep femoral artery is involved in the
tumoral process and is not always reachable for
revascularization.
In 1993, Favre et al.9 reported a new extra-
anatomical bypass through the ilium in 5 patients.
Katsamouris et al.10 reported 5 cases of iliopopliteal
bypass, with 1 tunnelization through the iliac wing.
Recently, Enzmann et al.4 described a series of 8
cases of this bypass which is the largest series, but
only 2 procedures were performed for neoplastic
complication.
This kind of bypass can also be performed for
groin infection.11,12
Even if it is not often performed, tunneling
through the iliac crest is feasible, reliable, and repro-
ducible. It requests no special skills and does not
need muscle flap for wound coverage.
Unlike studies about vascular reconstruction dur-
ing tumoral lower limb resection,5,13,14 our study
reports only cases of lower limb salvage for vascular
complication following initial tumoral treatment.
This technique is also recommended in case of pre-
vious vascular surgery followed by radiation ther-
apy because anatomic revascularization is at high
risk.
All our patients were treated in emergent situa-
tion (critical ischemia or spontaneous hemorrhage).
We used a prosthetic graft in those bypasses for
multiple reasons. Saphenous vein is a good substi-
tute for lower limb bypass, but diameter is small
for proximal anastomosis on the iliac artery, even
if it is feasible. Furthermore, tunneling of a saphe-
nous vein with important angles exposes to a risk
of kink, external compression, and false aneurysm
on the iliac bone. This risk is lower with a prosthetic
graft. Finally, preserving ipsilateral saphenous vein
can be relevant when femoral vein is potentially
occluded.15
Short- and long-term primary patency rate in our
study, as well as reintervention rates, was compara-
ble to rare studies about extra-anatomical obturator
bypass.7 Nevertheless, small patient number of our
study does not allow robust statistics.
Limb salvage rate is acceptable in our study.
Indeed, secondary intervention after oncological
resection is a very challenging situation, in a young
patient population. Those acceptable results request
active collaboration between surgeons, oncologists,
and interventional radiologists, as well as optimal
preoperative multidisciplinary strategy planning
and postoperative surveillance.
Volume -, - 2020 Secondary extra-anatomic infrainguinal bypass following lower limb tumoral resection 5
Acceptable patency rate of this extra-anatomical
bypass is promoted by the nonatherosclerotic and
local arterial involvement with healthy distal ar-
teries. Bypasses performed for nonatherosclerotic
disease have good outcomes in regard with athero-
sclerotic disease. This is secondary to the excellency
of the distal bypass outflow, and the absence of
atherosclerotic evolution of arteries proximally
and distally to the bypass.
Limitations of our study are the small patient
number, its retrospective design, and the absence
of control group.
CONCLUSION
Secondary iliopopliteal bypasses through the iliac
wing following lower limb tumoral resection have
acceptable results. It is a valid option for limb salvage
especially after local radiation therapy and tumoral
resection. Multidisciplinary management is neces-
sary to obtain acceptable results and follow-up is
mandatory. Those results should be confirmed by
larger study.
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