Plate 166

The graft is brought through the previously made tunnel, with great care being taken to avoid kinking or twisting of the graft. The leg must be straightened to ensure that the length of the graft is adequate and the tension appropriate (Figure 26). The common femoral, superficial femoral, and profunda femoris arteries and any additional tributaries are now cross-clamped, and a common femoral arteriotomy is performed in the usual manner (Figure 27). Identifiable disease at the origin of the profunda femoris artery suggested by arteriography or by direct inspection may require femoroprofunda endarterectomy or patch angioplasty with the performance of this anastomosis. The proximal anastomosis is then performed in a similar fashion (Figure 28). Upon completion of the heel of the anastomosis, a No. 4 coronary dilator is passed distally to ensure that no stenosis has occurred at this location (Figure 29). If the dilator cannot be passed, the anastomosis must be redone or a prosthetic graft procedure must be undertaken. The anastomosis then is continued as previously described with careful flushing maneuvers performed immediately before completion (Figure 30). The completed femoropopliteal reconstruction lies comfortably within its tunnel with no tension, twisting, or kinking (Figure 31).

Careful palpation for pulsation of the vein graft distally and the artery distal to the popliteal anastomosis is performed to confirm patency. Completion arteriography should be performed via an angiocatheter introduced through a side branch of the saphenous vein with injection of 25 to 30 mL of contrast over 15 seconds. Routine arteriography confirms a technically perfect reconstruction and provides accurate assessment of the graft runoff. Any defects must be corrected if a successful outcome is to be expected. Intraoperative pulse volume recording may be used to assess the immediate hemodynamic improvement.

Meticulous hemostasis must be attained. Anticoagulation may be reversed with protamine sulfate if required by continued oozing. The incisions are then closed in layers in the usual fashion. Dry sterile dressings are employed.

The cardiopulmonary status must be observed carefully and often in an intensive care setting. Distal pulses should be palpated hourly for the first 24 hours and subsequently at regular intervals. Many surgeons use low-molecular-weight Dextran infusions of about 20 mL per hour for the first 24 hours, especially if a low popliteal or tibial vessel anastomosis was performed. The patients begin ambulation on the day after surgery and many can be discharged home within 4 days. Aspirin is given for its platelet effects. Noninvasive vascular laboratory testing in the postoperative period is valuable to assess hemodynamic improvement and the success of the bypass procedure. Special attention is given to the care of the feet. All efforts should be directed to controlling risk factors, such as smoking, and careful postoperative follow-up is imperative to enhance long-term benefit. Early or late occlusion is the most frequent complication. Graft occlusion is manifest by loss of pulses, pallor, pain, paresthesias, and loss of function. Noninvasive vascular laboratory studies may be helpful, whereas repeat arteriograms will verify the occlusion. If the occlusion occurs in the early period after surgery, immediate exploration without arteriography is warranted.