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vascular system

I N F R A I N G U I N A L A RT E R I A L P R O C E D U R E S

Stefano J. Bordoli, MD, and John W. York, MD*

Over the last decade, therapeutic interventions for lowerextremity peripheral arterial disease have grown in volume

and complexity with the advent of endovascular therapies.1

Although adding endovascular skills to the vascular sur-geon’s armamentarium may improve versatility, choosing between medical therapy, endovascular options, and openoperations can still be challenging. The TransAtlantic Inter-Society Consensus (TASC II) Working Group was created tohelp with these decisions in patients with lower extremityarterial disease. These guidelines were created to help select between open and endovascular treatment on the basisof the specic arterial disease pattern. Although TASC Alesions (i.e., < 10 cm stenosis or 5 cm occlusion of the super-cial femoral artery [SFA]) will likely have greater benetfrom less invasive endovascular therapy, TASC D lesions(i.e., common femoral artery or tibial trifurcation occlusion)are best treated with open reconstruction. TASC B and C

lesions lie between these extremes, where recommendationsfor either modality of treatment are more challenging andthe results less predictable. 2

An infrainguinal procedure is indicated in patients withcritical limb ischemia (CLI), classically dened as rest painor tissue loss, as the benet-to-risk ratio favors intervention.First-line therapy for patients with claudication should be atrial of smoking cessation, a supervised exercise program,and best medical therapy before any type of intervention isconsidered. A possible exception to this is the patient withlifestyle-limiting symptoms who is unable to perform his orher occupation or activities of daily living due to disablingshort-distance claudication. The conservative treatment ofclaudicants is a standard of care based on the benign naturalhistory of disease, which predicts a 10-year amputation rate

of less than 10% without intervention.3

However, peripheralarterial disease is also a predictor of poor survival. Patientswith an ankle-brachial index (ABI) less than 0.9 or greaterthan 1.4 are at signicantly increased risk for all-cause andcardiovascular mortality. 4 A review of 2,240 revasculariza-tions at our center revealed a dismal 5-year survival depend-ing on the indication for operation, that being 46% for restpain and 30% for tissue loss. 5 It is critically important toensure aggressive medical therapy and modication ofcardiovascular risk factors in patients with CLI.

Preoperative Evaluation

history and physical examination

A thorough history and physical examination are crucialfor accurate assessment of the patient’s atherosclerotic

Financial disclosure information is located at the end of this chapterbefore the references.

* The authors and editors gratefully acknowledge the contribu-tions of the previous authors, William D. Suggs, MD, andFrank J. Veith, MD, to the development and writing of thischapter.

disease. During the history, particular attention should bepaid to distinguishing the etiology as ischemic pain from

other causes of pain (i.e., lumbar musculoskeletal/neuritic,arthritic, or neuropathic pain). Pain suggesting peripheralarterial disease as the cause of presentation will be effortinduced, consistently reproducible, and relieved with rest.True rest pain may improve with the limb in a dependentposition, such as hanging the foot down off the bed to sleep.Ischemic pain is usually associated not only with decreasedpulses but also muscle atrophy, decreased skin temperature,dependent rubor, and hair loss. The examiner should alsolook for subtle signs of tissue loss such as ulcerations, sug-gesting advanced CLI. The presence of surgical scars willgive clues to the nature and extent of any previous vascularoperations, including previous saphenous vein harvest.Importantly, a thorough pulse examination should be per-formed to assess the patient’s extent of disease. This baselineinformation provides a basis for comparison if the diseasesubsequently progresses and may help determine theapproach used to salvage the limb.

noninvasive testing

Noninvasive tests are helpful in providing objectiveassessment of the arterial circulation beyond the physicalexamination. Such studies include the ABI, pulse volumerecordings (PVRs), and toe pressures.

The ABI is determined by dividing the higher of the anklepressure readings from the anterior tibial and posteriortibial arteries in each lower limb by the higher of the two brachial pressures. Normal circulation typically yields anABI of 0.92 to 1.2; claudication, an ABI of 0.91 to 0.50; and

limb-threatening ischemia, an ABI of 0 to 0.5. It is vital toremember, however, that lower extremity pressure mea-surements are less reliable in patients with heavily calciedvessels (i.e., diabetics and patients with end-stage renaldisease). In these patients, ABIs may be falsely elevated as aresult of the higher cuff pressures required to occlude calci-ed vessels, which may not occlude even with pressures of300 mm Hg.

PVRs are obtained by means of calibrated air-cuff plethys-mography. Standard blood pressure cuffs are placed atdifferent levels of the lower extremity, and the increases inpressure within the cuffs resulting from the volume increaseduring systole are recorded as pulse waves. Tracings exhib-iting a brisk rise during systole and a dicrotic notch are char-acterized as normal, those exhibiting loss of the notch and amore prolonged downslope are characterized as moderatelyabnormal, and those exhibiting a attened wave are charac-terized as severely abnormal [ see Figure 1]. Absolute ampli-tudes on PVRs are not directly comparable between patients;however, serial PVRs from a single patient are highly repro-ducible and thus are quite useful for following the courseof severe peripheral arterial disease in individual cases. 6 Amajor disadvantage of PVRs is the inability to differentiateproximal femoral disease from iliac occlusive disease. 7

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Toe pressures are measured with a small cuff inatedaround the base of the great toe. Similar to measuring brachial blood pressure, the pressure at which ow returnswhen the cuff is deated is recorded as the toe pressure. Thereturn of ow can be measured by photoplethysmographyor laser Doppler. 8 Although the ABI may be falsely elevatedin diabetic patients due to calcied tibial vessels, toe systolic blood pressures are more reliable. 9 Toe pressures of greaterthan 30 to 45 mm Hg have been suggested as indicativeof good healing potential in patients with tissue loss, with

diabetic patients probably requiring pressures at the higherend of this range. 10

imaging

Duplex ScanningDuplex scanning is a useful noninvasive method of

assessing the aortoiliac circulation for inow disease. A 1987trial found that duplex scanning was highly sensitive (89%)and specic (90%) in predicting an iliac stenosis of 50% orgreater. 11 Two subsequent trials corroborated these ndings,reporting sensitivities ranging from 81 to 89% and specici-ties ranging from 88 to 99%. 12,13 Below the inguinal ligament,arterial duplex scanning helps locate hemodynamicallysignicant vascular lesions and plan for revascularization.

Duplex scanning is also useful to evaluate veins for poten-tial use as conduits. At our institution, infrainguinal bypassis performed with an autogenous-rst conduit strategy as itcarries superior patency over nonautogenous conduit. 14,15 Although it has been suggested from experimental evidencethat an autogenous collar may increase the patency ofnonautogenous bypasses, a recent prospective trial showedno difference with or without vein collar for below-knee

popliteal or tibial targets.16

Preoperative B-mode ultrasoundimaging revealing continuous great saphenous vein (GSV)with a minimum diameter of 2.5 mm is suggested, withgreater than 3.0 mm being preferred. 17 Although duplexscanning has traditionally been the modality for evaluatingthe GSV for conduit, computed tomographic angiography(CTA) may have high specicity for GSV diameter andtherefore circumvent the need for an additional duplexstudy. 18

Arterial duplex scanning has been increasingly employedin performing infrainguinal bypasses to both popliteal andtibial vessels without preoperative angiography. Wain andcolleagues reported a limb salvage rate of 86% achievedwith this approach; completion arteriography matched therunoff status predicted by duplex scanning in 96% of cases. 19 Another group reported 1-year patency of 80% performingfemoropopliteal bypasses without preoperative arterio-graphy, using conrmatory arteriograms at the time ofoperation only. 20

Magnetic Resonance AngiographyMagnetic resonance angiography (MRA) yields quality

arterial images and may be more sensitive than angiographyin imaging distal lower extremity runoff vessels. 21 Develop-ments such as gadolinium enhancement, multistationexamination, and the oating table technique have furtherimproved the resolution of MRA, 22–24 to the point wheremany institutions that use current forms of MRA no longerroutinely obtain preoperative angiograms. The developmentof time-resolved imaging of contrast kinetics (TRICKS) MRAhas further improved the accuracy of MRA for assessing thedistal vasculature in preparation for a bypass. 25 When usedin conjunction with arterial duplex scanning, MRA has thepotential to replace contrast arteriography in the evaluationof patients with distal arterial occlusive disease.

The use of gadolinium enhancement for MRA, however,is not risk free. Over the last decade, several groups havelinked gadolinium-based contrast administration to a rare

Normal

Mildly Abnormal

Moderately Abnormal

Severely Abnormal

Figure 1 Tracings exhibiting a brisk rise during systole and adicrotic notch are characterized as normal, those exhibiting loss ofthe notch and a more prolonged downslope are characterized asmoderately abnormal, and those exhibiting a attened wave arecharacterized as severely abnormal.

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and sometimes fatal condition known as nephrogenicsystemic brosis (NSF). 26 NSF is characterized by rm andindurated skin plaques about the extremities and trunk,although deeper structures such as muscle, fascia, andlungs can also be affected. 27 The population most at risk arepatients receiving hemodialysis, as well as patients withacute kidney injury or stage 4 chronic kidney disease.Patients admitted with a proinammatory event (i.e., majorsurgery, infection/sepsis, thrombotic event) were also foundto be at higher risk for NSF. 28

Computed Tomographic AngiographyCTA has become a viable alternative to both MRA and

conventional digital subtraction angiography for imagingthe aortoiliac region and the lower extremity arteries.Current variants of this modality (e.g., 16-detector row CTA)have been shown to be as accurate as conventional angio-graphy for imaging distal vessels. As a consequence, opera-tive planning can be done without the need for an invasiveangiographic procedure. CTA has also shown promise in theevaluation of graft-related complications, including graftstenosis, aneurysmal changes, and arteriovenous stulas. 29–31

ArteriographyContrast angiography remains the gold standard for the

evaluation of patients with distal arterial occlusive disease.A complete evaluation of the existing arterial disease fromthe aorta to the pedal vessels is necessary for diabeticpatients, who frequently have multilevel occlusive disease.Obtaining intra-arterial pressure measurements acrosssuspicious lesions at the time of angiography signicantlyimproves detection of clinically signicant stenosis. Thesystolic pressure gradient across the lesion should also bemeasured: gradients greater than 15 mm Hg are consideredhemodynamically signicant. 32

A large series of diagnostic angiograms by a single vascu-lar surgeon revealed an overall complication rate of 3.8%where the femoral artery approach was used 93% of the

time. Increased age, smoking, and an operating time ofgreater than 30 minutes were associated with an increase inoverall complications. 33 The same group published an earlierseries revealing an increased risk of local, nervous system,and major complications when the axillary access approachwas chosen over the femoral approach. 34 For diagnosticlower extremity arteriography, an experienced group hasshown that the low brachial artery access approach has alow complication rate of 0.44%. 35

Renal insufciency is an important complication of angi-ography: 6.5 to 8.2% of patients who undergo arteriographyexperience some degree of nephrotoxicity associated withcontrast agents. 36,37 Patients who have preexisting azotemiaand whose baseline creatinine concentrations exceed2.0 mg/dL are at highest risk for renal complications afterangiography. Elderly patients typically have lower creati-nine clearances for a given serum creatinine level and thusshould always be considered at higher risk for nephrotoxic-ity. All possible precautions should be taken to limit therenal insult. Preprocedure volume expansion with infusionof either isotonic saline or sodium bicarbonate is renalprotective. Meta-analyses have not shown either to be moreeffective than the other. 38 Patients with chronic renal insuf-ciency may benet from acetylcysteine administration,

with some groups reporting signicantly less change in theirserum creatinine when compared with a control groupafter a contrasted computed tomographic scan. 39 During theprocedure, the operator should use the smallest volume ofcontrast agent that will provide an adequate study. There issome evidence to suggest that the use of nonionic iso- andlow-osmolar contrast agents can decrease the incidence ofrenal impairment, and nonionic iso-osmolar agents mayhave even greater benets for diabetic patients with chronickidney disease. 40–42

Femoropopliteal Bypass

Patients with an indication for revascularization and suf-cient imaging to conrm an inow and target vessel may be considered for femoropopliteal bypass. Such patients willhave adequate inow based on imaging and an above- or below-the-knee popliteal artery with patent distal runoff tothe foot. A patient with signicant isolated SFA disease will benet most from the shortest bypass possible; therefore, anabove-the-knee popliteal bypass should be considered. Thepatient with SFA disease and popliteal involvement willlikely require a below-the-knee popliteal bypass. Even if the

popliteal artery segment that is targeted is occluded distally, bypass to this segment can be considered with at least a7 cm length blind segment popliteal artery. 43 An isolatedpopliteal artery segment is dened as at least 7 cm of patentpopliteal artery proximal to the terminal occlusion, with atleast one major collateral branch vessel, as determined byarteriography. 42 A more recent Italian series with 51 bypasse sto blind segment popliteal arteries for patients with CLIresulted in a 5-year limb salvage rate of 90%. 44

operative technique

Above-the-Knee BypassThe patient is placed in the supine position with the thigh

externally rotated. A support is placed behind the lower

knee, and the knee is exed approximately 30°. This affordsoptimal positioning to expose the popliteal artery and toharvest the GSV. The common femoral artery is best exposedwith the leg straight.

Harvesting the GSV The GSV can be harvested througha continuous incision, intermittent skip incisions, orendoscopically [ see Figure 2].

At our institution, we perform GSV harvest through eithercontinuous or intermittent incisions. Dissection begins in thegroin, and this portion of the incision can also be used forexposure of the femoral artery. This incision is made onengerbreadth lateral and distal to the edge of the pubictubercle and is angled toward the medial knee. The saphe-nofemoral junction is carefully mobilized, and the tributar-ies are ligated with silk ties. As dissection continues distally,the main trunk of the GSV is progressively elevated, and alltributaries are identied and ligated. When placing ties onthese branches, care is taken not to tie them too close to thevein as they may impinge on and narrow the ow lumen.After the proximal and distal ends are ligated, the vein isincised, removed from its bed, and placed into a basin con-taining heparinized saline. Before ligating and removing thevein, be sure to measure the length of conduit required to

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perform the bypass with the leg in a fully extended position.The vein is best assessed for adequate length once both theorigin and the target vessel have been exposed. A smallcannula is passed through the distal end of the divided vein,and the vessel is irrigated with heparinized saline to expelany liquid blood or clot and to locate any leaks. Leaks arerepaired with 6-0 or 7-0 polypropylene (Prolene) in a fashionthat will repair the leak but not narrow the ow lumen.Care should also be taken when ushing the vein against amanually occluded end so as not to overdistend the veinand cause endothelial damage.

Step 1: exposure of femoral artery A vertical skin inci-sion is made over the femoral artery pulse, with the startingpoint slightly above the inguinal crease and extending dis-tally for 10 to 12.5 cm [ see Figure 3a]. If the GSV harvest will be performed on this side, a compromise can be made withan incision placed between where the other two would be.Divided lymphatics should be carefully ligated. Self-

retaining retractors are placed both proximally and distallyin the wound, and the lymphoadipose tissue is gentlyretracted medially [ see Figure 3b].

The deep fascia is opened along the femoral artery [ seeFigure 3c], and the sheath of the artery is opened along itsaxis [see Figure 3d]. The common and supercial femoralarteries are mobilized, and Silastic loops are placed aroundthem [ see Figure 3e]. These vessels are then elevated slightly,and the origin of the profunda femoris artery, which mustalso be controlled, comes into view typically lateral andposterior to the common femoral artery. A clue as to thelocation of the profunda femoris artery is by nding thechange in caliber as the common femoral artery dividesinto the SFA. Dissection of the origin of the deep femoralartery must be performed carefully so as not to injure thecollateral vessels coming off the artery. A large branch of theprofunda femoris vein, the lateral femoral circumex vein,typically crosses anterior to the artery at this level. This branch should be ligated and divided to help mobilizationof the deep femoral artery.

Step 2: exposure of proximal popliteal artery For theapproach to the popliteal artery, the surgeon moves to theopposite side of the table. The leg should be exed to 30°,

Figure 2 Shown is the appropriatefemoropopliteal bypass, above knee: legposition. Continuous or interruptedskin incisions are made in the thigh andupper leg to permit harvesting of thegreat saphenous vein.

with a support placed under the proximal calf. A longitudi-nal incision is made in the lower third of the thigh justanterior to the sartorius muscle and is extended close to themedial aspect of the knee [ see Figure 4a]. The deep fasciaanterior to the sartorius is opened, and the sartorius isrotated away from the vastus medialis and retracted poster-iorly. The popliteal artery is identied by retracting thevastus medialis muscle anteriorly; the artery is typicallythe most supercial vascular structure seen through thisexposure [ see Figure 4b].

The femoral sheath is opened [ see Figure 4c]. At this level,there is almost always a network of venules surroundingthe artery, which must be carefully dissected away fromthe arterial wall and ligated if necessary. Division of theadductor magnus tendon may be required to yield adequateexposure of the proximal portion of the popliteal artery [ seeFigure 4, d and e]. The popliteal vein is then separated fromthe artery, taking care to avoid injury to arterial or venous branches during this process. The popliteal artery is freed

for a length of approximately 3 to 4 cm, and vessel loops areplaced proximally and distally [ see Figure 4f ].

If the proximal popliteal artery appears markedly scle-rotic and unsuitable for anastomosis to the graft, the expo-sure must be extended to the middle portion of the artery.To achieve this extended exposure, the hamstring musclesand their tendons are mobilized and retracted posteriorly.The medial head of the gastrocnemius can be divided closeto the medial condyle of the femur if necessary. Next, thesheath of the popliteal artery is opened farther distally,and the tributaries of the veins surrounding the artery arefurther dissected away from it. Dissection of the middleportion of the popliteal artery may be facilitated by exingthe knee; this measure relaxes the artery, thereby allowing

it to be readily drawn closer to the supercial level of theexposure.

Step 3: creation of tunnel Implantation of the graft may be started in either the femoral artery or the popliteal artery;the former is our usual preference. Before the anastomosesare constructed or intravenous heparin is infused, a tunnelis created under the sartorius muscle by means of eithera tunneler or an aortic clamp with a red rubber catheter


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Lymphoadipose Mass

Deep Fascia

a b c

d e

Sartorius

Femoral ArterialSheath

Figure 3 Depicted is exposure of the femoral artery. ( a) A longitudinal skin incision is made over the pulsation of the femoral artery.(b) Lymphoadipose tissue is retracted to expose the deep fascia overlying the course of the femoral artery. ( c) The deep fascia is incised, exposingthe femoral arterial sheath, which is then opened along its axis ( d). (e) The common, supercial, and profunda femoris arteries are mobilized andencircled with Silastic vessel loops.

attached to it to mark the tunnel. Alternatively, a subcutane-ous tunnel can be performed via numerous routes. A disad-vantage is this typically requires more conduit length, but itis advantageous if there is concern for segmental revision ofthe graft in the future as much of the graft is easily accessiblein the subcutaneous tissue.

Step 4: construction of proximal anastomosis to femoral

artery Intravenous heparin is routinely administered 3minutes before vascular clamps are applied or vessel loopstightened. Before the proximal anastomosis is begun, theproper length of the graft should be determined to ensureadequate length and no redundancy. The common femoral,profunda femoris, and supercial femoral arteries areoccluded with clamps or vessel loops, whereas small side branches can be occluded with a 2-0 silk Potts tie or clip thatwill later be removed. A longitudinal arteriotomy is made in

the common femoral artery with a No. 11 knife blade and isextended with Potts scissors. The length of the opening inthe artery should be approximately twice the diameter of thevessel. If the edges of the arteriotomy are calcied and theatheromatous intima overlaps the cut edge, the diseasedintima should be excised with arteriotomy scissors or tackeddown with suture to prevent hemodynamically signicantdissection. The GSV is reversed, bringing the distal vein endto the femoral artery. As this is generally the smaller end ofthe vein graft that will be anastomosed to the larger femoralartery, it is ideal to nd a branch point on the vein graft tospatulate and include at the proximal anastomosis. Alterna-tively, better size match can be achieved with a nonreversedsaphenous vein after the valves are lysed.

Once the vein graft is spatulated and right-angle cornersare removed, the anastomosis is started at the heel witha double-armed 5-0 polypropylene suture. The rst needle


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a b

cd

e f

AdductorMagnus

AdductorMagnusTendon

HighestGenicularArtery

Figure 4 Depicted is medial exposure of the proximal popliteal artery. ( a) An incision is made in the lower third of the thigh, anterior to thesartorius. ( b) The deep fascia is incised, and the sartorius is retracted posteriorly, allowing the popliteal artery to be readily palpated. ( c) Thepopliteal arterial sheath is opened, exposing the vessel and its surrounding venules. The adductor magnus tendon may be seen coveringthe proximal end of the artery ( d), and it may have to be divided ( e) to provide better exposure of the artery. ( f ) The popliteal artery, freed of thevenous plexus, is mobilized between two vessel loops.

should be passed from outside to inside at the heel of thevein graft; then the same needle should travel from inside tooutside at the distal end of the common femoral arteriotom y.With equal suture lengths, these should be tied together,with three throws leaving the knot on the outside. Allsubsequent bites should ideally be from inside to outsidethe artery to tack down any potential dissection planes andwill continue proximally in a running fashion toward the

toe. These careful bites should approximate the edge of thevein to the edge of arteriotomy, and the length of travel between bites will depend on the remaining vein graft ver-sus arteriotomy length. If necessary, excess vein length can be remedied by trimming the toe length shorter or extendingthe arteriotomy. We recommend performing the more chal-lenging side of the anastomosis rst for approximately halfthe length of the arteriotomy. This is followed by running


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the other arm of suture from the heel and continuing aroundthe toe to meet the rst arm of suture. These are tiedtogether with six knots after forward- and back-bleeding theanastomosis and ushing with heparinized saline to ensureexpulsion of any potential clot or air.

Step 5: placement of graft in tunnel The graft is thenmarked on its top side to ensure that it does not become

twisted when brought carefully through the tunnel. Thegraft is brought through the tunnel either by using an aorticclamp, red rubber catheter, or specically designed tunnellersystem (i.e., Scanlan Tunneler ). At this point, the graft isdistended with inow by releasing each femoral artery branch clamp after clamping at the distal vein graft. Thiswill test for signicant leaks at the anastomosis or withinthe vein graft as bleeding welling up in the tunnel will benoticed in a short time. Subjectively testing ow from thedistal graft at this time will also let the surgeon know if thegraft may be kinked or twisted within the tunnel or if thereis a problem at the proximal anastomosis.

Step 6: construction of distal anastomosis to popliteal

artery Proximal and distal ow to the target area of thepopliteal artery is occluded with clamps or vessel loops,whereas small side branches are temporarily occluded witha silk Potts tie or temporary clip. A longitudinal arteriotomyis made with a No. 11 knife blade and is extended with Pottsscissors to a length about twice as long as the vessel is wide.

The end of the reversed GSV is in the operative eld atthis time and is prepared for the anastomosis with appropri-ate length spatulation. Double-armed 6-0 polypropylenesuture is used; the rst bite should pass from outside toinside at the heel of the vein graft and then with this sameneedle from inside to outside at the proximal end of thepopliteal arteriotomy. With equal suture lengths, theseshould be tied together with three throws, leaving the knot

on the outside. The rest of the anastomosis is completedin the same fashion as the femoral anastomosis describedearlier. Finally, the sutures are tied together after forward-and back-bleeding the anastomosis and ushing with hepa-rinized saline to ensure expulsion of any potential clot or air[see Figure 5]. Depending on the tibial runoff, as was revealed by the preoperative arteriogram or CTA, we check the feetat this point to ensure that there is graft-dependent arterialow. One can feel (pulse) or hear (continuous waveDoppler) an improvement in ow that is diminished withgraft occlusion at this time.

Below-the-Knee BypassWhen occlusion or signicant stenosis renders the proxi-

mal and middle portions of the popliteal artery unsuitablefor graft implantation, the distal portion of the vessel may be used for the target vessel anastomosis instead.

Step 1: GSV harvest and exposure of femoral artery TheGSV is harvested, prepared, and reversed in the samemanner as described above. The femoral artery exposure isaccomplished in essentially the same way as it would be inan above-the-knee bypass.

Figure 5 Shown are details of the anastomotic suturing, which isbegun at the heel and continued until the sutures meet from theopposite side of the anastomosis of the artery and the great saphenous

vein graft. Equal bites of all layers of each vessel are included in eachstitch, all of which are placed under direct vision.

Step 2: exposure of popliteal artery below the knee Withthe knee exed at 30° and supported by a bump under thedistal thigh, a longitudinal skin incision is made at themedial proximal leg one ngerbreadth posterior to the tibia[see Figure 6a], exposing the crural fascia [ see Figure 6b]. Caremust be taken to avoid injury to the GSV during the skinincision. When a GSV graft is to be used, the same incisioncan serve for both harvesting the remote portion of the veinand exposure of the artery.

The crural fascia is opened along its bers [ see Figure 6c],

its distal attachments are separated from the semitendinosusand gracilis tendons, and the two tendons are mobilizedproximally and, if necessary, divided. The medial head ofthe gastrocnemius is retracted posteriorly [ see Figure 6d], andif necessary, the soleus muscle is separated from the tibiawith electrocautery to expose the popliteal artery and vein[see Figure 6e]. The artery is carefully isolated for a distanceof 3 to 4 cm, and vessel loops are placed proximally anddistally.


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a b c

d e

GracilisTendon

CruralFascia

Medial Head ofGastrocnemius

Soleus

Popliteus

SemitendinousTendon

Figure 6 Depicted is medial exposure of the distal popliteal artery. ( a) An incision is made one ngerbreadth behind the posteromedial surfaceof the tibia. ( b) The crural fascia is exposed. ( c) The fascia is incised, exposing the vascular bundle. ( d) The medial head of the gastrocnemius isretracted posteriorly and the soleus muscle is taken down off the tibia if necessary, exposing the distal popliteal vessels. ( e) The distal poplitealartery is freed and mobilized between vessel loops.

Step 3: creation of tunnel Tunneling for a below-the-knee femoropopliteal bypass is carried out through theHunter canal, through the upper popliteal space, and nallythrough the region behind the popliteus muscle. It is essen-tial to pass the tunneler through the anatomic space betweenthe heads of the gastrocnemius muscles to avoid graft kink-ing or shearing during ambulation and muscle contraction.Following successful tunnel creation, the patient should begiven an appropriate dose of intravenous heparin.

Steps 4 through 6 Steps 4, 5, and 6 of a below-the-kneefemoropopliteal bypass include creating the proximalanastomosis to the femoral artery, passing the graft throughthe tunnel, and creating the distal anastomosis of the veingraft to the distal popliteal artery. These steps are carriedout in much the same way as the corresponding steps in anabove-the-knee bypass. Completion angiography may beperformed to conrm the adequacy of the distal anastomosisand verify the position of the graft in the tunnel [ see Figure 7].

outcome evaluation

Femoropopliteal bypasses performed with the GSV areassociated with 4-year primary patency rates ranging from68 to 80% and limb salvage rates ranging from 75 to 80%. 45 Femoropopliteal bypasses performed with polytetrauoro-ethylene (PTFE) grafts yield acceptable patency and limb

salvage rates above the knee but are signicantly less

successful below the knee.46

Newer vein harvesting techniques may help improveoutcome. Meta-analysis comparing open and endoscopicharvesting did reveal a signicant benet for wound infec-tion and dehiscence with endoscopic techniques. 47 However,the impact of harvesting technique on graft patency has been less evident. A retrospective review of femoral arteryto below-the-knee revascularizations revealed a nonsigni-cant improvement in 21-month patency with endoscopicvein harvest (92.8%) compared with open harvest (80.6%),whereas limb salvage rates were not different. 48 In contrast,a retrospective review by Pullatt and colleagues showed sig-nicant superior 5-year primary patency for single-incisionGSV harvest (59%) in comparison with a minimal incision

technique with (44%) or without endoscopy (33%).49

Operato rexperience or specic technical factors during endoscopicharvest may account for differences in outcomes. 50

Completion arteriography is helpful for evaluating thetechnical adequacy of the bypass and should be performedroutinely following infrainguinal arterial reconstructions.Mills and colleagues prospectively evaluated routine com-pletion arteriography performed on 214 patients undergoinginfrainguinal revascularization to the popliteal or tibial


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Figure 7 Femoropopliteal bypass, below knee: completion arterio-gram. A completion arteriogram from a patient who underwent below-the-knee femoropopliteal bypass for a nonhealing toe amputation siteshows runoff through all three tibial vessels.

arteries. 51 Signicant technical problems were discovered in8% of the bypasses, including 6% with popliteal targets and12% with distal targets.

Infrapopliteal Bypass

Bypasses to target arteries distal to the popliteal arterymay be indicated for patients with CLI when there issignicant distal popliteal or tibioperoneal trunk disease.Infrapopliteal bypasses are performed to various segmentsof the posterior tibial artery, the anterior tibial artery, or theperoneal artery, in that order of preference. A tibial arterytarget is used only if its lumen runs without obstruction intothe foot, although bypasses to isolated tibial artery segmentsand other disadvantaged outow tracts have been per-formed and have remained patent for more than 4 years. 52,53 Generally, the peroneal artery is used only if it is continuouswith one or two of its terminal branches, which communi-cate with foot arteries [ see Figure 8]. Neither the absence of aplantar arch nor vascular calcication is considered a contra-indication to a reconstruction. 52,54 With both femoropoplitealand infrapopliteal bypasses, stenosis of less than 50% of the

Figure 8 Infrapopliteal bypass. An arteriogram from a 65-year-oldfemale with rest pain in the right foot who underwent in situ bypassto the middle portion of the peroneal artery shows communication ofthe peroneal artery with foot arteries and reconstitution of the dorsalispedis artery.

diameter of the vessel may be acceptable at or distal to thesite chosen for the target anastomosis. This decision shouldtake into consideration conduit length.

operative technique

Bypasses to tibial arteries should ideally be performedwith autogenous vein grafts, and either the reversed (as pre-viously described [ see Femoropopliteal Bypass, above]) or thein situ technique [ see In Situ Bypass, below] may be used,with equal results. Placement of a tourniquet proximal to thedistal incision allows the distal anastomosis to be performed

without extensive dissection of the tibial vessels or applica-tion of clamps, which could be traumatic to these smallvessels. 55 Exposure of the inow vessel (i.e., the femoralartery or the popliteal artery) is achieved in the same way asin the femoropopliteal bypass procedures described above.Accordingly, bypasses to tibial and peroneal arteries are bestdescribed in terms of the approaches required for exposureof these vessels and the tunnels required for routing the bypass conduits.


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Exposure of Posterior Tibial ArteryThe proximal portion of the posterior tibial artery is

approached via an incision just distal to the below-the-kneepopliteal incision. The deep fascia is incised, the gastrocne-mius is retracted posteriorly, and the soleus is separatedfrom the posterior surface of the tibia. The posterior tibialartery will be located at the distal portion of the incision,where it can be dissected and isolated with vessel loops. The

distal posterior tibial artery is approached via a longitudinalincision medially along the posterior edge of the tibia [ seeFigure 9]; deepening this incision along the posterior tibialismuscle and the posterior surface of the tibia allows exposureof the posterior tibial artery. The tunnel from the poplitealfossa to the distal posterior tibial artery is made just belowthe muscle fascia, ideally with a long, gently curved clamp.Alternatively, it can be tunneled subcutaneously.

Exposure of Anterior Tibial ArteryTo expose the proximal portion of the anterior tibial

artery, a longitudinal anterolateral incision is made in theleg midway between the tibia and the bula over the appro-priate segment of patent artery [ see Figure 10a]. The anteriorincision is carried through the deep fascia, and the bersof the anterior tibial muscle and the extensor digitorumlongus are separated to reveal the neurovascular bundle.The accompanying veins are mobilized and their branchesdivided to allow visualization of the anterior tibial artery,which can then be carefully mobilized [ see Figure 10b]. Withthe artery mobilized, further posterior dissection can be per-formed, and the interosseous membrane can then be visual-ized and incised in a cruciate fashion to allow for anatomictunneling, which may also require an additional medial inci-sion. Careful blunt nger dissection via this anterior incisionand through the incised interosseous membrane and fromthe popliteal fossa via the medial incision facilitates creationof an adequate tunnel without injury to the numerous veinsin the area [ see Figure 10c]. Alternatively, the tunnel for the

bypass may be placed lateral to the knee in a subcutaneousplane, although this will require a longer conduit.

The distal anterior tibial artery is also approached via ananterior incision placed midway between the tibia and thebula [ see Figure 9]. A tunnel is made from the distal popli-teal fossa across and through the interosseous membrane,where it joins a counterincision at the anterolateral leg. Fromhere it can be tunneled to the distal incision. Once the distalanastomosis is complete and the graft has been drawnthrough the tunnel, any tendons that may be distorting

or compressing the graft in its course around the tibia aredivided; this measure proves necessary in most low anteriortibial bypasses.

Exposure of Peroneal ArteryThe peroneal artery is usually approached via the same

incision as the posterior tibial artery, with dissection contin-ued in the same plane but further lateral [ see Exposureof Posterior Tibial Artery, above]. The artery is located andisolated just medial to the medial edge of the bula. Inits distal third, however, and in patients with stout calvesand ankles, the peroneal artery should be approached viaa lateral incision [ see Figure 9], followed by excision of thebula.

For lateral exposure of the peroneal artery, a long segmentof bula is freed from its muscle attachments with a combi-nation of blunt and sharp dissection; particular care should be taken in dissecting along the medial edge of the bone because the peroneal vessels run just below this edge andare easily injured by instrumentation. Next, a nger is passedaround the bula [ see Figure 11a]; once this is done, the freeedge of bone is further developed by forcefully pushing aright-angle clamp inferiorly and superiorly, again beingcareful not to damage the peroneal vessels [ see Figure 11b].A right-angle retractor is passed behind the bone, and thebula is carefully divided with a power saw or bone cutter.The peroneal artery can then be dissected free from sur-rounding veins, isolated with vessel loops, and used for thedistal anastomosis. Gentle blunt nger dissection is required

to develop a tunnel from this lateral wound to the distalpopliteal fossa, and great care should be taken to avoid

Figure 9 Shown are incisions for bypasses to thedistal regions of the leg.


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a b c

Figure 10 (a ) An anterolateral incision is made midway between the tibia and the bula over the artery; small medial incisions are also madefor tunneling. ( b) The anterior incision is carried through the deep fascia, the anterior tibial muscle and the extensor digitorum longus areseparated, the accompanying veins are mobilized and divided, and the anterior tibial artery is mobilized. ( c) A tunnel is created with careful bluntnger dissection.

Figure 11 Lateral exposure of the peroneal artery typically requires excision of part of the bula; this is done by ( a) passing a nger behindthe bula, developing the free bone edge further with a right-angle clamp, ( b) passing a right-angle retractor behind the bula, and dividing thebone with a power saw or bone cutter.

injur y to the numerous veins in the area. Because the pero-neal artery is the least accessible of the three leg arteriesused for infrapopliteal bypasses and normally has the poor-est connections with the arteries of the foot, we recommendthat it be used as a distal implantation site only when theanterior and posterior tibial arteries are not suitable or if the

bypass is compromised by conduit length.

Exposure of Dorsalis Pedis ArteryWhen no adequate tibial target arteries are available, a

bypass to the ankle region or the foot may be performed.The dorsalis pedis artery is approached via an incision ontothe dorsum of the foot [ see Figure 12a]. The incision is curvedslightly and a ap raised so that the incision will not be

directly over the anastomosis [ see Figure 12b]. If the artery


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outcome evaluation

Infrapopliteal bypasses using autogenous conduit haveexpected 5-year primary patency rates ranging from 60 to67% and limb salvage rates ranging from 70 to 75% whetherthey are done with the reversed-vein technique or with thein situ technique. 57,58 For all such grafts, close patient follow-up and graft surveillance improve secondary patency rates.Reduced complications and decreased length of stay have been reported for patients undergoing distal in situ bypasse susing the endoscopic side-branch occlusion approach. 59

Pedal Bypass

Extension of the standard approaches to limb salvage hasled to the performance of bypasses to vessels below theankle joint [ see Figure 14 and Figure 15]. Such bypassesare indicated when the more proximal tibial vessels areoccluded, which frequently occurs secondary to failure of a

a

b

Figure 12 (a) The dorsalis pedis artery is approached via an incisionon the dorsum of the foot. ( b) The incision is curved and a ap raisedso that the incision is not directly over the anastomosis.

Figure 13 Shown is an arteriogram from a 72-year-old diabeticpatient who underwent a popliteal artery–dorsalis pedis artery bypasswith a reversed great saphenous vein graft for a nonhealing great toeamputation.

must be approached at the ankle, the extensor retinaculum

must be divided. Otherwise, the operation is performedin much the same fashion as a distal anterior tibial bypass[see Figure 13]. The posterior tibial artery can be approacheddown to a point several centimeters below the medialmalleolus.

In Situ BypassIn situ bypass is an acceptable alternative to reversed vein

bypass. In situ procedures were traditionally done throughlong skin incisions to access the GSV and its side branches.Subsequently, minimally invasive techniques were devel-oped to reduce the wound complications encountered whenan in situ bypass is performed via long skin incisions.

Suggs and colleagues described a minimally invasivetechnique of side-branch occlusion involving the use of anendoscopic vein harvesting system. 56 Their techniquerequires three skin incisions: two incisions for arterial accessand one 2 cm incision above the knee for insertion of anendoscopic device to locate and clip the side branches of thesaphenous vein. Once the proximal anastomosis is complete,the valves are lysed with a exible valvulotome passedthrough the distal end of the vein. Completion angiographyis then performed to conrm side-branch occlusion and toassess the entire reconstruction. 56


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more proximal bypass. The technique required for perform-ing bypasses to secondary branches in the foot is essentiallythe same as that required for performing bypasses to majorinfrapopliteal vessels.

Optimal illumination by means of head lamps is impor-tant for achieving technical success with plantar bypass, andloupe magnication is helpful when the vessel is less than1.5 mm in diameter. In addition, visualization of perimalleola rand inframalleolar arteries requires excellent preoperativeimaging studies.

These very distal bypasses offer a viable alternative to amajor amputation. Like infrapopliteal bypasses, they are best described in terms of the anatomic approaches to thedistal branch vessels. In what follows, we outline exposureof the plantar and tarsal arteries; exposure of the dorsalispedis artery is outlined elsewhere [ see Infrapopliteal Bypass,above].

operative technique

Exposure of Lateral and Medial Plantar ArteriesThe lateral and medial plantar branches are the continua-

tion of the posterior tibial artery in the foot [ see Figure 16].The lateral plantar artery forms the deep plantar arch and islarger than the medial plantar artery. If the lateral branchis occluded, the medial branch may enlarge and feed theplantar arch through collateral vessels.

The initial incision is made over the termination of theposterior tibial artery below the malleolus. The artery isisolated, and the incision is extended inferiorly and laterallyonto the sole. A direct approach to the individual branchesis difcult, for several reasons. First, because the skin of thesole is not easily retracted, adequate exposure of the lateral

and medial plantar arteries is hard to obtain if the incisiondoes not follow their course exactly. Second, because thesearteries are small in diameter and lie deep within the foot,they can be quite difcult to locate. Third, it is sometimeshard to distinguish the lateral plantar artery from themedial plantar artery. Dissection of the termination of theposterior tibial artery can help the surgeon make this dis-tinction. The lateral branch is usually located inferiorly whenthe foot is externally rotated on the operating table.

Posterior Tibial Artery

Peroneal Artery

Anterior Tibial Artery

Lateral Tarsal Artery

Dorsalis Pedis

Arcuate Artery

Deep PlantarArtery

Medial PlantarArtery

Lateral PlantarArtery

Figure 14 Shown are the major arteries of the foot, including thetwo major branches of the posterior tibial artery. The lateral plantarartery is usually the larger and ends in the deep plantar arch.

Figure 15 A completion arteriogram from a 62-year-old diabeticwith nonhealing toe ulcers who underwent a popliteal artery tomedial plantar artery bypass with a reversed great saphenous veingraft shows the distal anastomosis, with ow visible through a smallbut patent medial plantar artery.

PosteriorTibial Artery

Lateral PlantarArtery

Medial Plantar Artery

Figure 16 Depicted is exposure of the distal portion of the posteriortibial artery. The lateral and medial plantar arteries branch fromthis vessel and lie beneath the exor retinaculum and the abductorhallucis, which can be incised.


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Exposure of the proximal 2 to 3 cm of the plantar branche sis accomplished by incising the exor retinaculum and theadductor muscle of the great toe. More distal exposure ofthese branches can be obtained by dividing the medial bor-der of the plantar aponeurosis and the extensor digitorum brevis.

Exposure of Deep Plantar Artery and Lateral Tarsal Artery

The deep plantar artery and the lateral tarsal artery are branches of the dorsalis pedis artery. The deep plantarartery originates at the metatarsal level, where it descendsinto a foramen bounded proximally by the dorsal metatarsalligament, distally by the dorsal interosseous muscle ring,and medially and laterally by the bases of the rst andsecond metatarsal bones. As the deep plantar artery exitsfrom this tunnel, it connects with the lateral plantar arteryto form the deep plantar arch [ see Figure 17].

A slightly curved longitudinal 3 to 4 cm incision is madeover the dorsum of the middle portion of the foot, andthe dorsalis pedis artery is dissected distally down to its bifurcation into the deep plantar and rst dorsal metatarsal branches. The extensor hallucis brevis is retracted laterallyor, if necessary, transected, and the dorsal interosseousmuscle ring is split to allow better exposure of the proximalportion of the deep plantar artery. The periosteum of theproximal portion of the second metatarsal bone is thenincised and elevated. A ne-tipped rongeur is used to exciseenough of the metatarsal shaft to permit ample exposure ofthe deep plantar artery.

outcome evaluation

Bypasses to the dorsalis pedis artery and its branches haveyielded results comparable to those of bypasses to moreproximal tibial vessels, with 3-year primary patency ratesranging from 58 to 60% and limb salvage rates ranging from

75 to 95%.60–62 In one review, patency rates were higher inpatients who had an intact plantar arch than in those whodid not; however, failure to visualize the plantar arch onpreoperative arteriograms does not preclude the perfor-mance of these bypasses for limb salvage. With carefulfollow-up, the assisted primary patency rates for these graftshave been substantially improved. 63 The available reportsemphasize the need to repair failing grafts because their sec-

ondary patency was much better than that of failed grafts.In one study, patients who required shorter bypasses or hadlower preoperative C-reactive protein levels experiencedsignicantly better outcomes. 64 In some patients, occlusionof the distal tibial vessel necessitates performance of atibiotibial bypass to achieve wound healing. 54

Bypasses to plantar or tarsal vessels performed with veingrafts yield 2-year patency rates ranging from 65 to 75%and limb salvage rates higher than 80%. 6,65 In one report,the primary patency rate for these grafts was 74% at 1 yearand 67% at 2 years, and the limb salvage rate was 78% at2 years. 53

Alternative Bypasses Using More Distal Inow Vessels

Traditionally, the femoral artery has been the inow siteof choice for infrainguinal bypasses. Since the early 1980s,the supercial femoral, deep femoral, popliteal, and tibialarteries have all been used as inow sources when thesevessels were relatively disease free or when the amount ofautogenous vein available was limited.

The strategy of using more distal inow sources isparticularly applicable to inframalleolar bypasses, in whichvery long vein segments would be required to reach thedorsalis pedis or other pedal arteries from the usual moreproximal inow sites. Two studies from the latter half of the1980s reported that the patency rates in bypasses originating

LateralTarsalArtery

Dorsalis Pedis

Arcuate Artery

Deep Plantar Artery Figure 17 Shown is a dorsal view ofthe arteries of the foot. Exposure of thedistal dorsalis pedis artery ( insert ) high-lights the origin of the deep plantarartery and its downward course betweenthe rst and second metatarsal bones.This exposure is facilitated by lateralretraction of the extensor hallucisbrevis.


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ties or clips that will later be removed. A longitudinal arte-riotomy is made with a No. 11 knife blade and extendedwith Potts scissors. A Freer or Peneld elevator is used tond a plane between native artery and plaque, and this iscontinued along the diseased segment of artery. Care should be taken not to enter too deep of a plane, which would leavethe native artery too thin. The endarterectomized plaqueis removed en bloc or in several pieces if necessary. Gross

debris should be removed but again being careful not to thinout the native artery too much or cause a perforation. Thegoal is sufcient inow, which can be tested by releasedproximal occlusion, adequate outow to the supercialor profunda femoral artery, or both. If there is a proximalprofunda femoris artery stenosis and a distal end point can be reached, then the arteriotomy can be carried onto the pro-funda beyond that end point, leading to a profundaplasty.Care should be taken not to chase supercial femoral diseaseto a normal end point, although as this may never be reached,an adequate outow lumen is all that is necessary.

Step 3: Patch AngioplastyA vein (i.e., GSV), artery (i.e., occluded SFA), or prostheti c

(i.e., Dacron or bovine pericardium) patch should be usedfor common femoral artery angioplasty. The anastomosisshould begin at the more difcult apex and be performedwith 5-0 or 6-0 double-armed polypropylene suture depend-ing on the native artery size. The rst bite should pass at thepatch apex from outside to inside and then at the artery apexfrom inside to outside. With equal suture lengths, theseshould be tied together with three throws, leaving theknot on the outside. The patch will then be sutured alongeither wall in a running fashion to the halfway point of thearteriotomy, with artery bites continuing to be from insideto outside so as to tack up any potential debris or planes ofdissection. The other end of the suture will be used to runfrom the apex to the midpoint on the other side of thearteriotomy. At this point, the other end of the patch should

be cut to length and shape for its corresponding apex and asuture placed in the same manner as the previous with threethrows tied, leaving the knot on the outside. One side is thenrun down to the arteriotomy to meet the suture from theother end, and these knots are tied together. The last quarterof the patch is run to meet the other end to near-completion but is forward- and back-ushed from all branches and thenwith heparinized saline to remove any potential clot or air before the knot is tied.

outcome evaluation

Common femoral artery endarterectomy, with or withoutprofundaplasty, is a necessary tool with excellent outcomesthat should be a part of the armamentarium of all surgeonstreating infrainguinal occlusive disease. Ballotta and col-leagues described a modern 8-year single-center prospectiveseries of 111 patients with a mean follow-up of 4.2 yearswho underwent common femoral endarterectomy withpatch angioplasty for claudication, rest pain, or tissue loss. 69 Their 7-year results for primary patency, limb salvage, andfreedom from further revascularization were 96%, 100%,and 79%. The complication rate was 6.6% with eightinguinal lymph leaks only, all managed conservatively withresolution. The authors suggest that their use of spinal or

from the supercial femoral and popliteal arteries werecomparable to those in bypasses originating from thecommon femoral artery. 66,67 Grego and colleagues reviewedtheir popliteal-distal bypasses and found a 5-year primarypatency and a limb salvage rate of 57% and 64%, respec-tively. Performing the procedure emergently and usingPTFE for conduit were predictors of failure. 68 Given theseresults, surgeons should not hesitate to employ either the

popliteal artery or the SFA as an inow source. Use of thesedistal inow sites results in shorter grafts and allowsportions of the GSV to be preserved for other purposes.

An increasing number of limb salvage procedures aresecondary interventions. These secondary procedures aregenerally more difcult to perform because the access routesto the arteries have been previously dissected and becausethere frequently is little good autologous vein remaining.In some cases, patients present with gangrene developing below a functioning bypass or after a previous failed bypass.Some of these patients need nothing more than a short distalextension of their functioning bypass; others have onlyenough vein left to make up a short graft. For such patients,a tibiotibial bypass may be an effective alternative revascu-larization approach.

Lyon and colleagues reported their 11-year experiencewith tibiotibial bypasses, comprising 42 procedures in 41patients. 54 Ten bypasses were performed because previous bypasses failed; the remainder were performed because theamount of autologous vein available was limited. Approxi-mately 50% of the bypasses were to pedal or tarsal vessels.The patency rate at 5 years was 65%, and the limb salvagerate was 73%. 54

Common Femoral Artery Endarterectomy

Patients with isolated common femoral artery occlusivedisease and an indication for revascularization are bestserved with an open reconstruction versus an endovascularoption. 2 MRA, CTA, or arteriography should conrmadequate inow to the common femoral artery, as well asoutow to the supercial or profunda femoris artery, or both. Adjunctive profundaplasty may also be performeddepending on individual anatomy and pathology.

operative technique

The patient is placed in the supine position with the legstraight. If there is planned or potential use of the ipsilateralGSV for a patch, the knee can be slightly exed and the legexternally rotated.

Step 1: Exposure of the Femoral ArteryFemoral artery exposure is accomplished in essentially the

same way as it would be in the previously described bypass

procedures unless profundaplasty is planned, whichrequires further dissection and vascular control down theprofunda femoris artery.

Step 2: EndarterectomyIntravenous heparin is routinely administered 3 minutes

before vessel occlusion. Proximal and distal ow to theartery is occluded with clamps or vessel loops, whereassmall side branches are temporarily occluded with silk Potts


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11. Langsfeld M, Nupute J, Hershey FB, et al. The use of deepduplex scanning to predict hemodynamically signicantaortoiliac stenoses. J Vasc Surg 1988;7:395–9.

12. Moneta GL, Yeager RA, Antonovic R, et al. Accuracy oflower extremity arterial duplex imaging. J Vasc Surg 1992;15:275–83.

13. Legemate DA, Teeuwen C, Hoenveld H, Eikelboom BC.Value of duplex scanning compared with angiography andpressure measurement in the assessment of aortoiliaclesions. Br J Surg 1991;78:1003–8.

14. Klinkert P, Post PN, Breslau PJ, van Bockel JH. Saphenousvein versus PTFE for above-knee femoropopliteal bypass. Areview of the literature. Eur J Vasc Endovasc Surg 2004;27:357–62.

15. Donaldson MC, Whittemore AD, Mannick JA. Furtherexperience with an all-autogenous tissue policy for infrain-guinal reconstruction. J Vasc Surg 1993;18:41–8.

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18. deFreitas DJ, Love TP, Karthikeshwar K, et al. Computedtomography angiography-based evaluation of great saphe-nous vein conduit for lower extremity bypass. J Vasc Surg2013;57:50–5.

19. Wain RA, Berdejo GL, Delvalle WN, et al. Can duplex scanarterial mapping replace contrast arteriography as the testof choice before infrainguinal revascularization? J VascSurg 1999;29:100–7.

20. Ascher E, Hingorani A, Markevich N, et al. Lowerextremity revascularization without preoperative contrast

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nance angiography of peripheral runoff vessels. J Vasc Surg1992;16:807–15.

22. Fenlon HM, Yecel EK. Advances in abdominal, aortic, andperipheral contrast-enhanced MR angiography. MagnReson Imaging Clin North Am 1999;7:319–36.

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epidural anesthesia for all cases and the average 1.5-houroperative time account for the 0% perioperative mortalityand relatively low overall morbidity. They concluded thatcommon femoral endarterectomy is a safe, effective, anddurable operation for patients with isolated occlusivedisease of the groin.

Summary

Vascular surgeons will continue to treat an increasingvolume of patients with peripheral arterial disease by mini-mally invasive endovascular techniques, but the mastery ofopen infrainguinal reconstruction must always remain intheir armamentarium. The success of each procedure willrely not only on technical skill but also preoperative imagingand planning to ensure optimum inow, conduit, andoutow. The management of peripheral arterial disease,mastery of patient selection, and preoperative planning will be as important to patient outcomes as the mastery ofinfrainguinal arterial reconstruction techniques.

Financial Disclosures: Stefano J. Bordoli, MD, and John W. York, MD, have no relevant nancial relationships to disclose. Thischapter was previously authored by William D. Suggs, MD,and Frank J. Veith, MD, with disclosure made at the time ofinitial publication. This chapter has been reviewed, updated, andrereleased by the authors listed.

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Acknowledgments

Figure 1 Christine KenneyFigures 2, 5, 9 through 12, 14, 16, and 17 Tom Moore. Revisedand updated by Thom Graves, CMI.Figures 3, 4, and 6 Alice Y. Chen


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