Hybrid Lower Extremity Revascularization Avoiding Groin Re-Exploration in a Morbidly Obese Patient With Acute Limb Ischemia After Failed Femoral-Popliteal PTFE Bypass: A Case Report and Literature Review.

IntroductionWe present a case of acute limb ischemia (ALI) in a morbidly obese patient with prior femoro-popliteal artery PTFE bypass occlusion successfully treated with a hybrid femoral-to-posterior tibial artery bypass utilizing the previously occluded graft.Case ReportA 69-year-old morbidly obese woman presented with acute left leg pain and numbness with preserved motor function. Computed tomography angiography (CTA) demonstrates chronic superficial femoral artery and femoro-popliteal PTFE bypass occlusion with a new native popliteal artery thrombosis and loss of tibial runoffs. After systemic heparinization, the leg was revascularized through a small medial thigh incision and a jump PTFE bypass to the posterior tibial artery. The previously occluded femoro-popliteal artery bypass was accessed to re-establish proximal flow through a retrograde endovascular construction using a 7 mm by 25 cm Viabahn (Gore, Flagstaff, AZ) stent. This stent was used as a bridge with distal deployment within a new 6 mm PTFE graft, which was then anastomosed in an end to side fashion to a Linton patch of the posterior tibial artery. There were no postoperative complications, and the ankle-brachial-index was measured to be 0.98 with a CTA with runoffs confirming bypass patency.DiscussionALI in the setting of a prior bypass occlusion in a morbidly obese patient reflects the typical contemporary patient and disease complexity, which demands corrective revascularization with appropriate mitigation/prevention of other postoperative complications. A limited thigh exposure to access a previously occluded bypass can successfully restore in-line flow in these high-risk patients.ConclusionHybrid lower extremity revascularization is an alternative surgical modality to restore in-line flow to a lower extremity as a limb salvage option while avoiding groin re-exploration in a previously accessed groin for bypass construction in a morbidly obese patient.