varicocele is a collection of abnormally dilated , tortuous spermatic veins.1,2 the prevalence of varicocele is reported to be as high as 10%15% in the general population , 30%35% in men with primary infertility , and 69%81% in men with secondary infertility . the varicocele has clinical importance because it is the most common cause of male infertility and is correctable.1,35 the causes of varicocele are multifactorial , but in the end , the result is a pathological dilatation of the veins draining the testicles.6 varicocelectomy is by far the most commonly performed operation for the treatment of male infertility.7,8 a variety of surgical and nonsurgical approaches have been advocated for varicocelectomy . they include minimally invasive procedures , such as laparoscopic varicocelectomy and transvenous percutaneous embolization , and the traditional open surgical approach ( retroperitoneal , inguinal , and subinguinal).1,5,7,8 limb ischemia occurs because of a decrease in the blood flow to a limb , resulting in a potential threat to the viability of the extremity . unfortunately , not only is there a threat to the limb , but these patients are also at high risk for death . causes of limb ischemia could be embolus , thrombosis , or trauma ( iatrogenic , blunt , and penetrating ) . a 36-year - old hispanic male presented to the vascular clinic on february 4 , 2015 , with a history of progressive left lower extremity pain with walking for 1 month . the patient noted a marked decrease in his walking distance over 1 month before his evaluation . at presentation , he was able to ambulate 5075 feet only before the onset of left calf pain . on january 8 , 2015 he admitted to having complications postoperatively , consisting of a large left groin hematoma and left leg pain . the left groin hematoma resolved 1 week postoperatively , but the left leg pain was increasing , especially with ambulation . he was assured by the operating surgeon that his surgery was successful and that the leg pain was temporary . however , the patient presented to our vascular surgery clinic , seeking a second opinion . he denied any history of tobacco use , hypercholesterolemia , hypertension , diabetes mellitus , or lower extremity trauma . he was without any systemic complaints . at the time of presentation , the patient denied taking any medication . the lower extremity examination was remarkable for bilateral groin scars , no swelling or hematoma , absent left femoral and pedal pulses , and normal right femoral and pedal pulses . cardiac and other investigations were normal , although these do not exclude arterial emboli completely . computerized tomographic ( ct ) angiogram was requested , and the patient was asked to bring a copy of his previous surgery report . ct angiogram showed complete occlusion of the left common femoral artery up to its bifurcation with normal runoff ( figure 1 ) . the varicocelectomy surgical report denied any vascular complications apart from minor intraoperative bleeding from the left side controlled by stitches . the patient was informed about the ct angiogram finding and that he needed revascularization of his left leg with the possibility of using a vein graft . on february 7 , 2015 , through a left groin longitudinal incision , the left common femoral artery was controlled with vessel loops ( figure 2 ) . upon dissection , the femoral artery was observed to be completely destroyed , with no anatomical configuration except for fragments of the wall ( figure 3 ) . at the bifurcation , a reversed interposition saphenous graft between the left common femoral artery and its bifurcation was performed ( figure 4 ) . , the patient was doing well and ambulating normally . at 6-month follow - up , he had palpable pedal pulses bilaterally and no complaints . the patient provided a written informed consent and the ethical approval was obtained from the ethical committee of dr sulaiman al habib hospital , riyadh , saudi arabia . from the skin surgical incisions and the surgeon s brief operative report , we believe that the inguinal approach was used for varicocelectomy in our patient . in this approach , the position of the superficial inguinal ring is marked on the skin , approximately 35 cm over the inguinal canal . the incision is extended around 2 cm from the mark , following the natural lines of the skin . the spermatic cord is elevated , and any external spermatic veins that are running parallel to the spermatic cord or perforating the floor of the inguinal canal are identified and ligated . both layers of spermatic fascia are incised longitudinally , and all arteries , including the testicular artery , are preserved . all remaining inner spermatic veins , with the exception of the vas deferens vein , are clipped or ligated.813 hydrocele is the most common complication of varicocelectomy . recurrent varicocele , wound infection , testicular atrophy , and infertility are rare but significant complications . hematomas ( scrotal or wound ) are less than 1% after varicocelectomy.1416 in a literature review , over 5,000 patients pooled from 33 studies of varicocelectomy were evaluated . there were no vascular complications , and scrotal hematoma was very rare.6 a young patient with no vascular risk factors or trauma presenting with symptoms of leg ischemia demands a high index of suspicion for a list of rare causes of leg ischemia like popliteal entrapment , buerger s disease , embolisms , etc . in our patient , we had a high suspicion of surgical complication causing damage to the femoral artery . however , the surgeon report and the known complications of varicocelectomy made us question our preliminary diagnosis . cardiac and other investigations were normal , although these do not exclude arterial emboli completely . we hypothesized that during varicocelectomy through the inguinal approach , the surgeon had encountered a bleeding from the left groin ( most likely from branches of the common femoral artery adjacent to the surgical field , epigastric , or pudendal arteries ) ( figure 5 ) . in these circumstances if the surgeon can not identify the bleeding source , he should not apply blind sutures as that will cause further vascular and even nerve damage our patient had his varicocelectomy in a private hospital where all surgical specialties including vascular surgery are available . he managed to traumatize the femoral artery , which eventually led to its thrombosis and destruction . a thorough literature search using pubmed ( a search engine of the united states national library of medicine and the national institutes of health ) , medline database , and individual urology journals failed to find a similar report . to our knowledge , our case is the first to report leg ischemia ( vascular injury ) as a complication of varicocelectomy . during the inguinal approach for varicocelectomy , dissection deeper than the inguinal ligament should be avoided . direct pressure is applied , followed by careful dissection to locate and control the bleeding source . asking for a vascular surgeon s support is recommended . we have presented the case of a 34-year - old male with left leg ischemia that resulted from a varicocelectomy procedure .
varicocelectomy is the most commonly performed operation for the treatment of male infertility . 
 many surgical approaches are used as each of them has advantages over the other and is preferred by surgeons . 
 vascular injury has never been reported as a complication of varicocelectomy apart from testicular artery injury . 
 we present a 36-year - old male who developed leg ischemia post - varicocelectomy due to common femoral artery injury . 
 he was successfully treated by using a vein graft .