General Principles and Patient Selection

The primary indication for performing a femorofemoral bypass is the presence of symptomatic unilateral iliac artery occlusive disease. A more recent indication is completing a reconstruction after an aorto-uni-iliac endovascular graft placement for abdominal aortic aneurysm. The threshold for high risk and the decision to choose a femorofemoral bypass over an AFB are certainly not well defined, and criteria are likely to be somewhat different from surgeon to surgeon. The less satisfactory patency and hemodynamic performance of a femorofemoral bypass compared to an AFB makes the author much less likely to recommend its use in claudicants, who are generally lower risk and likely to live longer than those with critical limb ischemia.

A femorofemoral bypass depends on the ability of one iliac artery to supply adequate blood for both legs without causing a decline in flow to the donor leg. The surgical literature has confirmed that this concept is correct, at least when the patient is at rest as long as there is no significant disease in the donor iliac arterial system. If needed, a suboptimal donor iliac artery can often be improved using endovascular techniques to make it satisfactory for use as a donor vessel. Thus the primary considerations from an anatomic standpoint are: Does the patient have ipsilateral iliac artery disease that does not appear favorable for endovascular treatment? Is the contralateral iliac arterial system free of hemodynamically significant disease, and if not, can it be improved with endovascular techniques to make it a suitable donor artery? Is there reasonable common, deep, and/or superficial femoral artery target runoff on the ipsilateral side?

Preoperative Evaluation

A lower extremity segmental arterial noninvasive examination should be performed to calibrate the severity of disease and to serve as a baseline to which post-reconstruction studies may be compared. A good-quality CT angiogram may be sufficient for determining suitability for a femorofemoral bypass and operative planning. However, resolution might not be adequate to determine the level of disease in the common and external iliac arteries, particularly if there is significant calcification, which significantly degrades resolution. In such cases, a conventional transfemoral angiogram is preferred. In some cases it may be useful to perform a vasodilator (papaverine)-enhanced measurement of the pressure gradient between the aorta and the donor side femoral artery to determine the physiologic significance of any suspect donor iliac arterial lesion. Significant occlusive disease of the aorta itself is unusual in the face of at least one patent common iliac artery, but if the aorta is occluded, the occlusion must be addressed (endovascular in many cases) or another procedure must be considered.

Technique

The operation is performed with the patient supine. The operation may be performed with general, regional, or even local anesthesia. Perioperative prophylactic antibiotics are administered and continued for 24 hours. Specific antibiotic coverage is administered as necessary in cases with established remote infection and critical limb ischemia such that surgery cannot be delayed for a period to attempt to clear infection.

Femoral arteries are exposed through a longitudinal groin incision most often, because this allows more flexibility depending on findings at inspection of the target arteries. The graft is tunneled in the subcutaneous tissue from one groin incision to the other. The general strategy is to try to maximize the radius of curvature of any changes in the direction of the graft to prevent graft kinking. The tunnel forms an inverted U and should be brought well above the level of the groin incisions to prevent acute angulation of the graft at any point (Figure 1). Care must be taken to keep the graft anterior to the anterior abdominal fascia in most cases. The tunnel may be created using a tubular tunneler if one is available or with a combination of finger dissection and a large clamp. Special care must be taken when tunneling through areas of scarring from previous incisions where there might even be herniated abdominal contents at risk of injury during tunneling. Grafts are placed in the preperitoneal potential space only in very unusual circumstances, such as a uniquely thin subcutaneous layer or an abnormal abdominal wall (from radiation, scarring, etc.).

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