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INDICATIONS

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Only patients with severe and debilitating occlusive disease of a unilateral aortoiliac segment should be considered for femorofemoral bypass. Today, endovascular angioplasty and stenting have reduced the indications for both aortofemoral bypass and femorofemoral bypasses, but there remains the occasional patient in whom bypass is the preferred treatment. Not all patients with a long-standing unilateral aortoiliac occlusion can be recannulated by endovascular techniques. In those patients where recannulation cannot be accomplished, femorofemoral bypass may be the preferred operative option. The contralateral, or donor aortoiliac segment should be free of occlusive disease. In the case where there is occlusive disease on the donor side, balloon angioplasty and stenting may need to be performed first to assure adequate inflow. Unilateral claudication is the leading indication for femorofemoral bypass, but occasionally rest pain, ulceration and gangrene may be the indication especially in the presence of significant comorbidities in the elderly. In younger patients with unilateral claudication, femorofemoral bypass may be preferred over the more durable aortofemoral bypass to eliminate the risk of retrograde ejaculation in those patients desiring children. While the younger patients are generally healthier and the operation is less invasive than aortofemoral bypass, the long-term patency is reduced and these factors need to be considered in the decision making. Elderly patients may still have generalized arteriosclerosis, including coronary artery disease and hypertension, and careful selection remains important.

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PREOPERATIVE PREPARATION

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The anatomy is best defined by contrast angiography, CTA or MRA (figure 1) and the final reconstruction is shown in figure 2. Medical clearance is obtained as indicated. Intravenous antibiotic coverage is started on call to the operating room.

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ANESTHESIA

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Regional epidural anesthesia is most commonly used, but general anesthesia may be preferred by the patient or anesthesiologist.

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POSITION

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Patient is placed in the supine position.

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DETAILS OF PROCEDURE

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A linear incision is made in each groin over the femoral artery and the common femoral, the profunda femoris, and the superficial femoral artery are carefully isolated and encircled with Silastic vessel loops for control. It is important to dissect at least several centimeters of the profunda femoris to evaluate the presence of disease in this vessel, especially if indicated on preoperative imaging. If it is significantly involved, profunda endarterectomy or a profundoplasty should be considered, because this procedure appears to increase the longevity of graft function, especially if it is the main runoff vessel. Prior to giving heparin, a suprapubic subcutaneous tunnel is started with gentle subcutaneous finger dissection (figure 3) in both groins. A tunneling device then joins the 2 groin incisions and a Penrose drain is pulled through to secure the passageway. From the suprapubic position the tunnel must form a gentle curve to each groin to avoid kinking of the graft when it is pulled into place by ...

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