View Full Chapter Figures Only Tables Only Videos Only Print Share Email Send Email Your Name (required) ! Example: John Doe Email Address (required) ! Please enter a valid sender email address. Example: email@example.com CC Me Recipient Email Address (required) ! Separate multiple email address with semi-colons (up to 5). Subject Subject for your email. Message (Maximum characters: 1,000) Please enter your name Please enter your email address Please enter a valid recipient email address. Example:firstname.lastname@example.org Submit Cancel Thank you! Your email has been sent to: The recipient(s) will receive an email message that includes a link to the selected article. Recipients may need to check their spam filters or confirm that the address is safe. Return to: Send Another Email An error has occurred sending your email(s). Please try again later or contact an administrator at OnlineCustomer_Service@mheducation.com. Return to: Twitter Facebook Linkedin Reddit Get Citation Citation AMA Citation Kabbani LS, Henke PK. Kabbani L.S., Henke P.K. Kabbani, Loay S., and Peter K. Henke.Chapter 37. Surgical Revascularization of Infrainguinal Arterial Occlusive Disease. In: Minter RM, Doherty GM. Minter R.M., Doherty G.M. Eds. Rebecca M. Minter, and Gerard M. Doherty.eds. Current Procedures: Surgery New York, NY: McGraw-Hill; 2010. http://accesssurgery.mhmedical.com/content.aspx?bookid=429§ionid=40112051. Accessed June 22, 2017. MLA Citation Kabbani LS, Henke PK. Kabbani L.S., Henke P.K. Kabbani, Loay S., and Peter K. Henke.. "Chapter 37. Surgical Revascularization of Infrainguinal Arterial Occlusive Disease." Current Procedures: Surgery Minter RM, Doherty GM. Minter R.M., Doherty G.M. Eds. Rebecca M. Minter, and Gerard M. Doherty. New York, NY: McGraw-Hill, 2010, http://accesssurgery.mhmedical.com/content.aspx?bookid=429§ionid=40112051. Download citation file: RIS (Zotero) EndNote BibTex Medlars ProCite RefWorks Reference Manager © Copyright Tools Search Book Top Return Clip Chapter 37. Surgical Revascularization of Infrainguinal Arterial Occlusive Disease Loay S. Kabbani, MD; Peter K. Henke, MD + Indications Print Section ++ Disabling claudication.Critical limb ischemia, defined as rest pain or tissue loss. + Contraindications Print Section ++ Absolute ++ Debilitated patient with severe comorbidities.Unaddressed inflow disease.Lack of an appropriate distal target for revascularization. ++ Relative ++ Nondisabling claudication.Nonambulatory patient.Severe joint contractures. + Informed Consent Print Section ++ Expected Benefits ++ Restoration of adequate blood flow to the lower extremity, thereby relieving ischemic pain, preventing gangrene, and maintaining ambulation. ++ Potential Risks ++ The 30-day mortality and morbidity rates are 2% and 26%, respectively. Morbidity includes: Surgical site infection.Myocardial infarction.Renal and respiratory failure.Vein graft patency overall is reported to be 73% at 5 years versus 49% for a polytetrafluoroethylene (PTFE) graft. Primary and secondary vein graft patency at 5 years is reported to be 50% and 70%, respectively, with a limb salvage rate of 73%. + Equipment Print Section ++ No special equipment is needed other than a standard vascular instrument tray. + Patient Preparation Print Section ++ Ankle-brachial indices (ABIs) or segmental pressures.The arterial anatomy must be defined clearly. A lower extremity angiogram, CT angiogram, or MR angiogram may provide sufficient detail for operative planning.Preoperative stratification with a full history and physical examination. Eagle criteria, American Heart Association guidelines for perioperative cardiovascular evaluation for noncardiac surgery, or another cardiac risk stratification algorithm can be used to calculate the patient's perioperative risk for coronary events and need for further workup.All patients should receive optimal medical therapy in the perioperative period, including: Daily aspirin.β-Blockers to titrate the heart rate to < 70 beats/min.Statin therapy to achieve a goal low-density lipoprotein level < 100 mg/dL.Tight blood glucose control with a target level < 140 mg/dL (for at least the first 3 days postoperatively).Appropriate prophylactic antibiotics are delivered within 30 minutes of skin incision and are redosed as needed for prolonged cases (eg, intravenous cefazolin, 1 g preoperatively, then 1 g every 8 hours intraoperatively). + Patient Positioning Print Section ++ The patient should be supine with both arms extended; procedure-specific positioning is indicated later.A Foley catheter is inserted.A radial arterial line is placed. + Procedure Print Section ++ Principles of Open Infrainguinal Revascularization ++ Inflow ++ The artery from which the bypass will originate must have an adequate pressure and allow suturing. Significant vascular calcification can present challenges. ++ Outflow ++ The vessel should be the least diseased vessel with dominant blood flow to the foot. ++ Conduit ++ The great saphenous vein (GSV) has superior long-term patency rates for all infrainguinal bypasses.In the absence of an ipsilateral GSV, the contralateral vein may be used.Alternatively basilic, cephalic, or lesser saphenous veins may be used as a composite graft.The GSV may be used in situ, reversed, or nonreversed transposed with equivalent long-term patency results, depending on the surgeon's experience.Although prosthetic grafts have mediocre long-term patency rates in infrainguinal bypasses, they can be used if no other conduit is available. ++ Anatomy, Exposure, and Preparation of Proximal and Distal Targets ++ Figure 37–1: Anatomy of the target site. The mnemonic NAVEL aids in recollection of the anatomy; from lateral to medial, the Nerve, Artery, Vein, Empty space, and Lymphatics will be encountered—the latter is where a femoral hernia may occur.The GSV joins the femoral vein at the saphenofemoral junction.The common femoral artery (CFA) begins at the inguinal ligament as a continuation of the external iliac artery.The femoral artery bifurcates approximately 5 cm distal to the inguinal ligament into the superficial femoral artery (SFA) and the deep femoral artery, also known as the profunda femoris (PF), the latter traveling laterally and posteriorly. ++Figure 37–1Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Common Femoral Artery ++ Figure 37–2: Exposure and preparation for bypass. A vertical incision 3–5 cm in length is made proximal to the inguinal ligament and continued for about 3–4 cm distally over the femoral pulse.If the pulse is absent, the incision should be made 1–2 cm lateral to the pubic tubercle where the femoral artery is usually located.A calcified artery may be pulseless but is easily palpated.The femoral artery should be exposed longitudinally to avoid lymphatic disruption and the lymphatics dissected laterally; we ligate or clip larger lymphatics when present.A Weitlaner or cerebellar retractor is used to help expose the vessel.The CFA, SFA, and PF artery are dissected and isolated with vessel loops.The lateral circumflex femoral vein is located between the origins of the SFA and PF. During dissection of the femoral artery bifurcation, this vein tends to be injured and bleed if not sought out and carefully mobilized.We have found that the proximal CFA is best clamped using a Satinsky or a Dara clamp. The external iliac artery may be mobilized, instead, if it is a better vessel to clamp; this sometimes entails dividing the inguinal ligament, which is repaired at the end of the operation.A severely diseased CFA may require an endarterectomy with patch angioplasty in order to make it suitable for bypass grafting.Caution must be undertaken with this maneuver as suitable end points after endarterectomy are rare. ++Figure 37–2Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Popliteal Artery ++ Figures 37–3and 37–4: Exposure and preparation for bypass.Proximal popliteal artery (see Figure 37–3). The knee is flexed and a roll is placed under the thigh.The skin incision is made in the lower thigh at the superior edge of the sartorius muscle and below the muscle belly of the vastus medialis.If the ipsilateral GSV is used for conduit, then one incision may be used for both harvesting the vein and dissecting out the popliteal artery.Cutting the superficial fascia allows entry into the sheath of the sartorius muscle; this muscle is isolated and reflected posteriorly along with the semitendinosus and gracilis muscles.The popliteal fat space is exposed.The dissection is performed close to the femur, retracting the great adductor muscle anteriorly and exposing the adductor hiatus.The popliteal artery is found by palpation.Doppler localization is helpful in patients with larger legs and small nonpalpable arteries.Distal popliteal artery (see Figure 37–4). A roll is placed under the distal thigh.The incision starts 1 cm behind the medial tibial condyle, runs for 1–2 cm behind the posterior edge of the tibia, and then courses down the upper third of the leg; we extend it proximally or distally as needed.The medial head of the gastrocnemius is retracted posteriorly using a Weitlaner or an Adson retractor.A Beckman retractor is placed, lifting the soleus muscle up and the gastrocnemius muscle down.The popliteal artery is surrounded by two veins, and the tibial nerve lies posterior to it.Careful sharp dissection is carried out using Metzenbaum scissors.The popliteal artery gives off the anterior tibial artery and the tibioperoneal trunk 2–7 cm before diving into the soleus muscle.To expose the tibioperoneal trunk, follow the popliteal artery caudally, dividing the soleus muscle with cautery.The anterior tibial artery is isolated with vessel loops at its origin at the proximal end of the soleus muscle. ++Figure 37–3Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++Figure 37–4Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Posterior Tibial and Peroneal Arteries ++ Patient positioning. The patient should be supine with the thigh rotated 30–50 degrees.A bump is placed below the thigh to help exposure.A tourniquet or microvascular Heifitz clips may be used for homeostasis at the time of bypass.Figures 37–5 and 37–6: Exposure and preparation for bypass. Upper and middle leg: the incision is placed 1–2 cm behind the posterior edge of the tibia midway in the leg. This incision usually overlies the GSV.The fascia is cut and the gastrocnemius muscle is freed and retracted posteriorly while the insertion of the soleus muscle is taken down from the posterior aspect of the tibial bone, exposing the deep posterior compartment of the calf.Both the posterior tibial artery and, a little deeper to it, the peroneal artery lie inside this compartment.With the use of a tourniquet, only the anterior and lateral aspects of the vessels need to be exposed, and there is no need for circumferential exposure or vessel loops. ++Figure 37–5Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++Figure 37–6Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Anterior Tibial Artery ++ Patient positioning. The leg is maintained at 30 degrees of flexion and a roll is placed under the thigh.Exposure and preparation for bypass. The skin and fascia are incised over the space between the anterior tibial muscle and the long extensor of the toes.The anterior tibial artery runs with the deep peroneal nerve on top of the interosseous membrane.In the lower third of the leg the muscles are more tendinous and the anterior tibial artery runs behind the anterior tibial muscle and the extensor hallucis longus.The Doppler probe can aide in identifying the location of both the dorsalis pedis and posterior tibial arteries. ++ Preparing the Conduit ++ Vein Harvest ++ The GSV is harvested through a separate skin incision medial to the CFA incision. Cephalic, basilic, or lesser saphenous veins may also be harvested.Once the vein is removed, it should be placed in a solution containing heparin. The vein is distended gently and any leaks are addressed.Tributaries are ligated with 4-0 silk ties. ++ In-Situ Bypass ++ Here the vein is not mobilized from its bed except at the proximal and distal ends. As the vein is exposed, tributaries are tied off with silk ties.The proximal GSV is mobilized, excising the first valve under direct vision.Then the GSV is spatulated and anastomosed to the CFA.Once the clamps are released, the first competent valve will hold up; valve lysis is then performed using one of a variety of valvulotomes. It is essential to preserve the vein side branches to allow passage of the valvulotome. ++ Routes for Bypass and Creating the Tunnel ++ Figure 37–7A, B: The graft is tunneled before heparinization.Popliteal route. The graft is tunneled beneath the sartorius muscle but superficial to the adductor magnus tendon (Figure 37–7A).If the distal anastomosis target is the below-knee popliteal artery, then the graft should be further tunneled in an anatomic position (Figure 37–7B).Posterior tibial artery route. The GSV is mobilized for approximately 10 cm.The aponeurosis of the leg should be incised high enough to avoid angulation of the vein.In reversed bypasses, either a subcutaneous or an anatomic route may be used.The anatomic route follows the posterior edge of the sartorius, enters the popliteal fossa between the two heads of the gastrocnemius, and passes anterior to the soleus muscle to the posterior tibial artery.This route is used preferentially for reversed saphenous vein graft and prosthetics; it is less susceptible to the risk of superficial infections and is not subject to kinking when the knee is flexed.When using a subcutaneous route, a tunnel is made that runs along the anterior medial surface of the thigh and continues on the medial side of the knee and leg.The diameter of the tunneling instrument must be sufficient to create a tunnel wide enough to prevent compression.Peroneal artery route. When accessed through the medial approach, the trajectory is the same as for the posterior tibial artery.Anterior tibial artery route. In-situ bypasses: the lower part of the popliteal fossa is divided, and the interosseous membrane is freed and then incised longitudinally for 2–3 cm.A blunt instrument is passed from the anterior compartment to the popliteal fossa.The distal anastomosis should be performed far enough from the point where the vein graft crosses the interosseous space so that the vein is parallel to the artery.The path for a reversed GSV may follow the anatomic route behind the sartorius, between the heads of the gastrocnemius, before joining the anterior compartment. ++Figure 37–7Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt)Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Performing the Bypass ++ Before occluding the inflow, the patient is given an initial heparin bolus of 100 units/kg; the activated clotting time (ACT) is kept above 250 seconds.Figures 37–8 and 37–9: The arteriography is made using a No. 11 blade and then extended with Potts scissors.The graft is spatulated and a polypropylene suture (eg, Prolene) is used to create the proximal anastomosis. We usually use 5-0 Prolene suture for the CFA and 6-0 Prolene suture for the distal target vessels.After completing the proximal anastomosis, the inflow is released and the graft is distended and then marked for orientation. The graft is passed through the tunnel carefully making sure there are no twists.For the leg vessels a tourniquet may be used to ensure a bloodless field (see Figure 37–8).An arteriotomy is made in the distal vessels with a No. 11 blade, and a 1.5–2.5-mm coronary dilator is carefully passed to ensure patency. The graft is cut to size with the leg extended, and the end is spatulated. The anastomosis is created (see Figure 37–9).Before completion of the anastomosis the artery is back-bled and the graft is flushed.Some centers perform completion angiograms; we use intraoperative duplex ultrasonography to scan the inflow anastomosis, the outflow anastomosis, and the graft for any abnormalities. In cases of a threefold increase in flow velocities or a velocity above 300 cm/s, close evaluation is needed to identify technical errors, flaps, or retained valves.The groin wound is closed in at least three layers of 3-0 Vicryl, obliterating all the potential space.The leg wounds are closed by approximating the fascia only.The skin is closed with staples, interrupted nylon, or subcuticular stitches. ++Figure 37–8Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++Figure 37–9Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) + Postoperative Care Print Section ++ Doppler ultrasound signals should be checked frequently to monitor graft patency.Patients are maintained on a β-blocker, an antiplatelet agent, and a statin unless contraindicated.Antibiotics are stopped 24 hours after surgery unless there is an active infection (eg, an infected ulcer or toe).Epidural injection or patient-controlled analgesia may be used for postoperative pain management.Venous thromboembolic prophylaxis is started on postoperative day 1 using unfractionated heparin administered subcutaneously.Patients with significant edema and pedal wounds are treated with an Ace wrap and leg elevation.Sutures in the foot are removed only when the wounds are solidly healed, and not before 4 weeks. + Potential Complications Print Section ++ Local wound infections.Hematoma.Lymph leaks.Graft thrombosis. + Pearls and Tips Print Section ++ Vessel exposure in previously operated groins requires patience and care. Doppler insonation is useful for locating difficult-to-palpate arteries and grafts.Sharp knife dissection is also helpful in groins that are very scarred.Patients should continue to take aspirin preoperatively as this improves graft patency. However, clopidogrel is associated with excessive bleeding, and we recommend stopping this drug 7 days before the operation.Perioperative antibiotics, excellent homeostasis, and good incision closure technique are essential to decrease postoperative problems.If there are no distal targets, amputation may be required. The level of amputation may be determined based on segmental pressures and the angiogram.A below-the-knee amputation should heal if the popliteal pressure is > 50 mm Hg or there is a patent PF artery. + References Print Section ++Branchereau A, Berguer R. Vascular Surgical Approaches. New York, NY: Futura; 1999. ++Zelenock G. Mastery of Vascular and Endovascular Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.