Chapter 37. Surgical Revascularization of Infrainguinal Arterial Occlusive Disease

• Disabling claudication.
• Critical limb ischemia, defined as rest pain or tissue loss.

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.

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%.

• No special equipment is needed other than a standard vascular instrument tray.

• 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).

• 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.

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 ...