Introduction The incidence of prosthetic graft infection after bypass surgery ranges from 0.2% to 5%, depending on location, co-morbid diseases and host defense mechanisms. The rate of vascular graft infection was reported to be up to 10% for femoropopliteal bypass (1). In spite of surgical treatment, the amputation rate can be up to 67%. Groin is more prone to this type of complication due to its prox- imity to the genitalia and perineum, the relatively super- ficial position of the graft, and wound healing problems frequently present in these arterially compromised patients (2). The therapeutic plan depends on the infec- tion severity and location, involved bacteria and the pres- ence of vascular complications. Herein, we present our treatment strategy for a patient with severe Methicillin Resistant Staphylococcus Aureus (MRSA) infection and proximal pseudo-aneurysm after a femoropopliteal bypass with a prosthetic graft. Case report A 72-year-old woman underwent a right femoropopliteal bypass with a prosthetic graft and endarterectomy of the common femoral artery for critical ischaemia of the lower limb. The patient was known to suffer from arteri- al hypertension and had a history of a transient ischaemic attack (four month previously). On the right lower limb she had a chronic ulcer on the distal calf. Ten days after bypass, skin graft was used to cover her leg ulcer. Five days later, she was discharged with anticoagulant therapy. One month after the first surgery, she returned to the hos- pital with pain in the right groin, pus secretion from the incisional wound and high fever (39°C). Local inflam- matory signs were significant. The bypass was function- al and leg ulcer completely healed. At hospital admission she had leukocytosis (15.000/mm 3 ) and the pus culture revealed MRSA infection, which was sensitive to Vancomicine and Teicoplanin. Intravenous Teicoplanin at 400 mg / day was initiated. Most of the pus was evacuated at the bedside. The ultrasound examination revealed a pseudo-aneurysm of the proximal anasto- mosis. When the sepsis ceased, the patient was brought to the operating room and the following strategy was applied : Step 1 A right lateral extra-anatomic bypass with a prosthetic graft was done between the external iliac artery and the distal part of the old graft, away from the inflammatory area (Fig. 1A). The anastomosis was end-to-side proxi- mally and end-to-end distally. The new graft passed from the retroperitoneal space to the subcutaneous area of the thigh. Step 2 After the new incisions were closed, the previously oper- ated groin area was opened and the pseudo-aneurysm was revealed. The common femoral artery was ligated at origin. The proximal anastomosis and 80% of the graft were excised. The debridement was done to the entire inflammatory area and included the surrounding tissue Acta Chir Belg, 2008, 108, 738-740 Simultaneous Extra-anatomic Bypass and Abdominal “Flag Flap” for Lower Limb Salvage in a Patient with Severe Post-Bypass Anastomotic Groin Infection M. Fodor*, L. Fodor**, ***, C. Ciuce* Department of Vascular Surgery*, Department of Plastic Surgery**, First Surgical Clinic, Emergency District Hospital, Cluj-Napoca, Romania ; Department of Plastic and Reconstructive Surgery***, Rambam Health Care Campus, Haifa, Israel. Key words. Vascular graft infection ; extra-anatomic bypass ; flag flap ; free tissue transfer. Abstract. The incidence of prosthetic graft infection after bypass surgery ranges from 0.2 to 5%, depending on location, co-morbid diseases and host defense mechanisms. In spite of surgical treatment, the amputation rate can be up to 67%. Herein, we present our treatment strategy for a patient with severe Methicillin Resistant Staphylococcus Aureus infec- tion and pseudo-aneurysm after a femoropopliteal bypass with a prosthetic graft. An extra-anatomic bypass without touching the previously operated groin area (aseptic time) was done at the beginning. Radical debridement (septic time) and simultaneous abdominal “flag flap” were performed in the same surgical procedure to save the lower limb.