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Surgical bypass of the femoropopliteal segment is reserved for patients with severe claudication and impending limb loss manifested by ischemic rest pain or tissue necrosis. Typically, such patients have generalized atherosclerosis and a high incidence of significant coronary artery or extracranial carotid artery occlusive disease. Multiple risk factors—including cigarette smoking, hypertension, diabetes mellitus, and hyperlipoproteinemia—can be identified in the majority. Careful selection of candidates for operation is of utmost importance, weighing the expected benefit against the potential risk.
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Aortography with full evaluation of the distal runoff is mandatory to identify and exclude more proximal occlusive disease and to ensure adequate graft runoff. Noninvasive vascular laboratory studies—including duplex ultrasound scanning, segmental limb pressures and segmental limb plethysmography—aid accurate physiologic assessment and serve as a baseline for estimation of the response to therapy.
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Careful assessment of cardiopulmonary function is most important. An electrocardiogram and chest x-ray are obtained and further investigations may be prompted by the history or physical examination. Cardiac evaluation with an ultrasonic echo or radionuclide imaging stress test may be prudent, as may be pulmonary function studies. Further investigation may be prompted by history, physical examination, or these initial studies. Immediately preceding operation, catheters are placed for monitoring the central venous pressure, arterial pressure, and urinary output. Prophylactic antibiotic therapy is begun before operation and continued for 24 to 48 hours. The entire abdomen and both lower extremities are shaved from the nipples to toes bilaterally early on the day of operation.
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General anesthesia or occasionally spinal anesthesia is employed with careful attention given to maintaining satisfactory hemodynamic parameters.
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The patient is placed supine on the operating table.
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The lower abdomen and appropriate limb are prepared in the usual manner to allow full mobility and exposure of the extremity. The foot is placed in a clear plastic Lahey bag, after which a clear plastic drape may be applied to the skin with special care anteromedially over the areas of planned incision. If the contralateral greater saphenous vein is to be used as the graft, the opposite extremity must be prepared in a similar fashion. If there is any question concerning the adequacy of inflow from the aortoiliac segment, the entire abdomen ...