++
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 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 patients in whom 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 ensure 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 patients desiring children. While 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 still may have generalized arteriosclerosis, including coronary artery disease and hypertension, and careful selection remains important.
+++
PREOPERATIVE PREPARATION
++
The anatomy is best defined by contrast angiography, computed tomographic angiography, or magnetic resonance angiography (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.
++
Regional epidural anesthesia is used most commonly, but general anesthesia may be preferred by the patient or anesthesiologist.
++
Patients are placed in the supine position.
+++
OPERATIVE PREPARATION
++
The hair is removed with clippers. The skin of the operative site is prepped and sterilely draped according to the surgeon's specifications. Then a time-out is performed.
+++
DETAILS OF THE PROCEDURE
++
A linear incision is made in each groin over the femoral artery, and the common femoral, profunda femoris, and superficial femoral arteries 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 ...