A linear incision is made in the groin over the femoral artery (Figure 10), and the common femoral, the profunda femoris, and the superficial femoral artery are carefully isolated. It is important to dissect at least several centimeters of the profunda femoris to evaluate the presence of disease in this vessel. If it is significantly involved, profunda endarterectomy or a profundoplasty should be considered, because this procedure appears to increase the longevity of graft function. A retroperitoneal tunnel is then made overlying the iliac artery and extending into the femoral incision (Figure 10) by blunt finger dissection from above as well as from below the inguinal ligament. It is important to make this tunnel on the artery so that the ureter does not become entrapped. Care should be given to anterior displacement of the ureter so that after the procedure it will overlie the prosthetic graft. Finally, it is important to remember that all of the dissections, aortic and femoral, and the tunnel should be completed before the patient is heparinized.
The graft is pulled into the groin incision (Figure 11) and the end beveled (Figure 12). Vascular clamps have been placed on the common femoral, the profunda femoris, and the superficial femoral arteries (Figure 13), and the linear arterotomy is made. It is not necessary to excise a button of artery wall.
The anastomosis is carried out in the same manner as the upper end-to-side anastomosis of the graft to the aorta (Figures 14 and 15). Just before completion of the femoral anastomosis, a clamp is placed on the opposite iliac limb of the graft and across the right common iliac beyond the bifurcation. The aortic clamp is opened momentarily to allow any potentially clotted material to be flushed out from the graft (Figure 16). The clamp is replaced and the anastomosis is completed. Then the aortic clamp is removed, with secure digital compression of the graft in order to ensure a gradually increased flow to the limb (Figure 17). The limb slowly is allowed to fill so that hypotension does not occur, much as was outlined in the aortic aneurysm procedure. A similar procedure is followed in completing the anastomosis of the graft to the left common femoral artery.
The incisions are closed in the routine manner. A running (0 or 1) monofilament suture with large wide bites is used for the midline incision, whereas the groin incisions are closed in layers with absorbable sutures. See Chapter 1.