Aortoiliac occlusive (inflow) disease can be treated in a variety of ways for patients who present with disabling claudication or critical limb ischemia. Percutaneous arterial interventions are often given early consideration for their less invasive nature and reasonable patency rates. Aortofemoral bypass graft is an excellent choice for good-risk patients with extensive aortoiliac occlusive disease not amenable to percutaneous options. There are circumstances whereby aortofemoral bypass may not be ideal secondary to high perioperative risk, hostile abdomen, or an infected field such that extra-anatomic bypass may be indicated.

Indications for femoral–femoral bypass include failed unilateral iliac endovascular intervention, heavily calcified unilateral iliac artery occlusive disease unable to be treated percutaneously, failed unilateral limb of aortobifemoral bypass, or limb occlusion after endovascular abdominal aortic aneurysm repair. Contraindications for femoral–femoral bypass include an infected common femoral arterial bed, bilateral iliac arterial occlusive disease, or a heavily scarred groin that precludes adequate soft tissue coverage over the prosthetic graft. Marginal surgical candidates may often be able to tolerate the procedure under regional or local anesthetic with sedation.

Preoperative planning for femoral–femoral bypass involves adequate imaging of the aortoiliac arterial to tree to ensure that the donor iliac arterial system is free of disease or can be adequately treated at the time of operation if necessary. Computerized tomographic arteriography (CTA), aortoiliac noninvasive duplex imaging, contrast arteriography, and magnetic resonance arteriography (MRA) are examples of preoperative imaging that can be utilized depending on patient comorbidities, surgeon preference, and whether intraoperative endovascular treatment will be necessary for the donor iliac artery. The common, superficial, and profunda femoris arteries, along with the remaining lower extremity arterial vasculature, will need to be imaged in a similar fashion to know what the runoff is and whether common or profunda endarterectomy will need to be performed at the time of operation.

Cardiac risk stratification and appropriate selective medical management with beta blockade, statin and antiplatelet agents is typically adequate prior to femoral–femoral bypass. If in question, nuclear stress imaging or stress echocardiography evaluation can be helpful in management, particularly in diabetics with poor functional capacity. Rarely is cardiac catheterization necessary.

In addition, complete blood count, creatinine, coagulation studies (if anticoagulated with warfarin), electrocardiogram, and chest x-ray within last 6 months are performed preoperatively. Consent is obtained for femoral–femoral bypass with prosthetic and possible arteriography including angioplasty and stenting of donor iliac artery (if anticipated), discussing the risks of infection, bleeding, myocardial infarction, stroke, death, and potential need for further surgery and intervention.

If intraoperative arteriography with possible aortoiliac intervention is anticipated, the case will need to be performed in a hybrid suite or with portable fluoroscopic imaging equipment. Various wires, sheaths, catheters, balloons, stents, contrast, and support staff need to be readily available. Standard vascular clamps and instruments, polytetrafluoroethylene (PTFE) or woven Dacron grafts of appropriate configuration, a tunneling device or aortic clamp for assistance with the suprapubic tunnel along with a continuous wave handheld sterile Doppler are necessary for the operation.