Figure 93-7. Arteriogram indicating preservation of the superficial femoral artery and popliteal arteries (A,B,C) with mid-calf

occlusions of all three infrageniculate vessels (D), with reconstitution of the dorsalis pedis artery in the foot (E). This anatomic

pattern of disease is amenable to “distal origin” vein grafting from the below-knee popliteal or proximal posterior tibial artery to

the dorsalis pedis artery.

Although exposure of the proximal posterior tibial and peroneal vessels can be gained by extending

the tibioperoneal trunk dissection distally, more distal exposure of these vessels is best gained through

targeted medial incisions. The posterior tibial artery is found beneath the divided musculotendinous

origin of the soleus muscle, and the peroneal artery is deeper and more lateral. The posterior tibial

artery at the level of the ankle is a relatively easier target given the proximity of the vessel to the skin

surface. The initial incision is made just posterior to the medial malleolus, and the artery exposed by

division of the overlying retinaculum. Further distal dissection allows access to the bifurcation and

medial and lateral plantar branches.70 The more distal peroneal artery may be approached laterally via

an incision placed over the distal fibula. Excision of a short segment of fibula will expose the underlying

artery.

2658

Figure 93-8. Exposure of the popliteal artery below the knee. The medial incision is made directly overlying the course of the

greater saphenous vein (A), with posterior retraction of the gastrocnemius muscle (B), to reveal the popliteal vessels in the

popliteal fossa (C).

The anterior tibial artery is typically approached from the anterolateral aspect of the calf (Fig. 93-9)

and is found deep within the anterior compartment with the adjacent deep peroneal nerve and anterior

tibial veins. It is best identified by developing the intermuscular plane between the tibialis anterior

muscle belly medially and the extensor digitorum longus laterally. The dorsalis pedis artery is easily

exposed through an axial incision on the dorsum of the foot just lateral to the extensor hallucis longus

tendon (Fig. 93-9). The artery lies just deep to the extensor retinaculum.

Figure 93-9. Placement of incisions for femoropopliteal and femorotibial bypass and for greater saphenous vein harvest. These

should avoid the incision lines for a below-knee amputation.

Autogenous Vein Bypass

10 Infrainguinal bypass surgery is best performed with autogenous vein conduit, preferably the

ipsilateral greater saphenous vein if available.96 This preference is particularly true for grafts extending

below the knee, where prosthetic conduits of Dacron or polytetrafluoroethylene have significantly

poorer patency rates. The first report of a femoropopliteal bypass graft using autogenous greater

saphenous vein in a reversed orientation was by Kunlin in 1951.8 Given the orientation of the vein

valves, the vein can be reversed such that the distal end of the vein is sewn to the proximal inflow

2659

artery and the larger proximal end of the vein is sewn to the distal outflow artery. However, it is our

general practice to utilize the greater saphenous vein in the nonreversed orientation as will be discussed

shortly. The vein is harvested through a long incision overlying the course of the vein or by more

tedious but less invasive sequential skip incisions with intervening cutaneous skin bridges (Fig. 93-7).

All side branches are ligated and after harvest, the vein is cannulated and gently dilated with a solution

containing heparin and papaverine to assess its suitability. Veins with chronic fibrosis or that fail to

dilate to a diameter of 3 mm or greater will likely have poor long-term function.

An alternative and less invasive approach to saphenous vein harvest involves the use of endoscopic

technology. In the case of harvesting of the greater saphenous vein, small skin incisions are made over

the saphenofemoral junction and the distal vein, and guided by a videoscope inserted distally and

advanced proximally, the side branches of the vein are serially identified and either cauterized or clipligated. The vein is then divided distally and proximally and removed, leaving the overlying skin

undisturbed. Advocates of this method cite a significant reduction in wound complication rates and

reduced rates of hospital stay.97 Although it has not been widely adopted by vascular surgeons, the

technique does have particular theoretical appeal in cases, for example, when contralateral saphenous

vein is to be utilized or the healing potential of the donor leg is compromised.98

For prosthetic grafts, a tunnel is usually fashioned through the subsartorial plane between the groin

incision and the above-knee popliteal space in the interests of protecting the graft from subsequent

infection. For vein conduits, it remains the surgeon’s preference as to whether the graft is tunneled

deeply or in a superficial location in the subcutaneous space. The more superficial configuration greatly

facilitates ongoing clinical examination and ultrasonographic surveillance as well as later surgical

revision, but carries a risk of graft exposure should there be wound healing problems. Occlusion from

trauma to grafts placed superficially has been of theoretic, but not practical concern.

It is our practice to perform the proximal anastomosis prior to the distal anastomosis. First, this

allows confirmation of adequate inflow before the bypass is performed. Second, performance of the

proximal anastomosis first allows the graft to be tunneled and tailored to appropriate length under

arterial pressure. This is of critical importance to prevent kinking along the length of the graft. Some

surgeons also prefer to mark the distended graft to ensure against mechanical twisting of the graft

during the tunneling process. An additional benefit of performing the proximal anastomosis first is that

adequacy of flow through the graft can be assessed, both before and after tunneling, with brief release

of the clamp.

Prior to occluding the inflow vessel, the patient is systemically anticoagulated with 5,000 to 10,000

units of heparin. Additional heparin is given throughout the procedure to maintain the activated clotting

time near the target range of 250 to 300 seconds. After allowing sufficient time for the heparin to

circulate, atraumatic vascular clamps are placed proximally and distally and the artery is incised. The

vein is then spatulated and a beveled anastomosis carried out. Typically a 5-0 monofilament suture of

polypropylene is used for the femoral anastomosis, a 6-0 is used at the popliteal level, and a very fine 7-

0 suture used at the tibial or pedal level. If the target tibial vessel is deep within the calf and visibility is

challenging, a technique of “parachuting” the heel of the distal anastomosis is often employed. After

completing the proximal anastomosis, the graft is carefully tunneled under arterial pressure.

Occasionally, such extensive calcification of the target vessel is encountered that the risk of a significant

injury from clamping, even with the minimally traumatic clamps in use today, is prohibitively high. In

such cases, proximal inflow and distal artery back-bleeding can be controlled by occlusion balloons

placed intraluminally. For distal anastomoses at the knee or more distal level, another alternative

technique is the use of a proximally placed sterile pneumatic tourniquet. This technique is particularly

advantageous when sewing to diminutive distal tibial or pedal targets, where the impact of a crush

injury or plaque dislodgment on graft function could be considerable. Removing the need for clamps by

using the tourniquet has two further advantages. First, it improves the operative visibility. Second, and

more importantly, given that less longitudinal and circumferential dissection is needed, the degree of

vessel spasm and venous bleeding that frequently accompanies vessel exposure at this level is kept to a

minimum.

Flow through the graft and the outflow arteries are assessed following completion of the bypass with

a continuous-wave Doppler. Ideally, a contrast angiogram is also performed after directly cannulating

the proximal graft (Fig. 93-10); this allows for immediate repair of any technical defects that are

identified, such as intraluminal thrombus, twisting or kinking of the graft, or retained valve cusps.73

Intraoperative completion duplex ultrasonography is an additional sensitive screen for hemodynamically

significant abnormalities within the graft, and its use further serves to prevent early graft loss caused by

2660

correctable technical problems.99,100

Figure 93-10. Intraoperative completion arteriograms of distal anastomoses to the above-knee popliteal (A), below-knee popliteal

(B), distal posterior tibial (C), and dorsalis pedis (D) arteries.

RESULTS

Table 93-2 Five-Year Patency and Limb Salvage Results of Infrainguinal Bypass

Grafting

Current reports of the 5-year results of reversed saphenous vein graft using modern techniques have

2661

been excellent, with primary and secondary patency rates of up to 75% and 80%, respectively and limb

salvage rates greater than 90% (Table 93-2).69,101–103

In Situ Grafting

There has been ongoing enthusiasm in some circles for in situ vein bypass grafting, whereby except for

its proximal and distal extent, the greater saphenous vein is left undisturbed in its native bed. This

technique was first described in 1962, but was later popularized by Leather and Karmody in the late

1970s.104,105 Recent reports of in situ saphenous vein grafting have indicated 5-year graft patency rates

of up to 80% and limb salvage rates of 84% to 95% (Table 93-1).57,102,106–108

The in situ approach minimizes trauma to the vein during excision and handling and in theory

enhances preservation of the vasovasorum and endothelium. It further lowers the considerable risk of

wound healing complications seen with traditional vein harvesting, increases vein utilization, and

facilitates the creation of more technically precise anastomoses because the proximal and distal vein

diameters are more closely matched to those of the inflow and outflow target vessels (Fig. 93-11). The

extent of the proximal vein mobilization is dictated by the location of the saphenofemoral junction

relative to the proposed site of the proximal anastomosis. It may at times be necessary to perform an

endarterectomy of the superficial femoral artery if the length of proximal vein is insufficient. Lysis of

the valve cusps is obligatory given the nonreversed configuration, and is facilitated by newer, less

traumatic valvulotomes that function safely through the blinded segments of undissected graft. Critics

of this technique argue that the advantages listed above have not translated into improved graft

function or patency. They further argue that the time required and dissection involved in finding and

ligating substantial side branches that can develop into physiologically important AVFs that “steal”

distal flow obviates the stated benefits of this approach.

Angioscopic-assisted valve lysis has been employed for over a decade, but has not gained widespread

favor. Although there is a significant learning curve with this technology and operative times, at least

initially, are significantly prolonged, advocates cite fewer wound complications, shorter hospital stays,

and decreased recuperative periods as potential benefits. Proponents of routine angioscopy for direct

visualization of valve lysis stress its particular utility in demonstrating such unsuspected endoluminal

venous pathology as phlebitic strictures, webs, and fibrotic valve cusps.109 This adjunct may be

particularly useful in cases in which arm vein is used because endoluminal pathology is more frequently

encountered and is presumably responsible, in part, for suboptimal results.110

Nonreversed Saphenous Vein Grafts

Recognizing the many practical advantages inherent to the in situ technique, some surgeons have

modified the approach to infrainguinal bypass grafting with venous conduit to incorporate several of the

same principles.56 In particular, if the harvested vein is tapered to any significant extent, it is used in a

nonreversed fashion. By optimizing the size matching between the artery and vein at both the proximal

and distal anastomosis sites as discussed previously, one can often accept for use, smaller veins than

would be unsuitable for reversed vein grafting. The nonreversed configuration also allows preservation

of the saphenous vein hood, which both extends the available conduit length and is especially beneficial

when the femoral artery is thick walled and diseased.

The vein is harvested and dilated in a similar fashion to reversed vein grafts and the cusps of the

proximal valve of the greater saphenous vein are excised under direct vision with fine Potts scissors.

There are currently two main types of valvulotomes available. The modified Mills valvulotome is a

short, metal, hockey stick-shaped cutter that can be introduced through the distal end of the vein or

through the side branches. After the proximal anastomosis is performed, and with the perfused conduit

on gentle stretch, the valves are carefully lysed in a sequential fashion by pulling the valvulotome

inferiorly. An alternative, recently designed self-centering valvulotome allows lysis of all valves in a

single pass and is thought by some to be less traumatic. Once acceptable pulsatile flow is ensured, the

distal anastomosis is performed in the standard fashion.

It is important to note that similar patency rates have consistently been demonstrated regardless of

which technique is applied, and so surgeon preference and comfort level is an acceptable reason for

choosing one method over another.107,108

Prosthetic Bypass

It is recommended that infrainguinal bypass surgery be performed with saphenous vein or an

autologous substitute whenever feasible given the clearly demonstrated enhanced patency rates.51,111

2662

Some institutions more frequently rely on prosthetic grafts. When the distal target is the above-knee

popliteal artery and the tibial outflow is relatively well preserved, this is an acceptable approach, as

patency rates in this situation approach those of vein grafts.112 A variety of surgical adjunctive

procedures, from patching the distal anastomotic target vessel to the creation of a distal AVF or various

autogenous vein cuffs interposed between the distal prosthetic and the target artery, have all been

attempted as a means of improving the patency rates of grafts extending below the knee.113 Polyester

(Dacron) and polytetrafluoroethylene (Teflon) grafts are the two main types of prosthetic available and,

as in other anatomic positions, available data show generally equal results with either choice. The entire

procedure is carried out through two small proximal and distal incisions between which the graft is

tunneled anatomically. The selection of a 6-, 7-, or 8-mm graft is dictated by the size of the native

vessels.

Figure 93-11. A: In the in situ method of infrainguinal reconstruction, the saphenous vein is left undisturbed in its native bed

except for at the proximal and distal anastomotic sites, in this case, the common femoral artery and the tibioperoneal trunk,

respectively. B: The saphenofemoral junction is transected in the groin, the venotomy in the femoral vein is oversewn and the

proximal end of the saphenous vein spatulated is prepared for anastomosis. C: After the first venous valve is excised under direct

vision, the graft is anastomosed end-to-side to the femoral artery. Flow is then restored through the vein graft and the valvulotome

2663

passed from the distal end to lyse the residual valves (D), before the distal anastomosis is performed (E).

Reoperative Bypass Surgery

As the patient population treated by vascular surgeons has increased in age, and more and more

challenging cases are accepted for primary treatment, there has been a corresponding increase in the

incidence of reoperative bypass surgery performed for infrainguinal arterial occlusive disease. Such

reoperative procedures are particularly challenging, both because of the scarring present at the inflow

and outflow target sites and because there is typically a lack of ipsilateral greater saphenous vein.

Whenever possible, the first problem is addressed by choosing anastomotic sites just above or below the

previous touchdown points, thereby avoiding dissection through often densely scarred tissue planes.

When ipsilateral greater saphenous vein is absent because of prior infrainguinal or coronary artery

bypass surgery or prior saphenous vein stripping, there are a number of alternative conduit sites

available. Investigators examining the consequence of using the contralateral greater saphenous vein in

these situations found it to be the optimal conduit; despite the presumably high incidence of

contralateral lower extremity as well as coronary occlusive disease in this population, the short- and

long-term impact was found to be minimal.90

In the absence of any greater saphenous vein, preoperative venous duplex ultrasonography is

employed to evaluate the cephalic and basilic veins of the arms and the lesser saphenous veins of the

legs in an effort to determine the best conduit available. Often the veins distal to the antecubital crease

are scarred and of small caliber, but their more proximal counterparts are often of excellent size and

quality. The use of arm veins in general can be technically challenging and for that reason has not been

universally adopted. The dissection of the basilic vein can be particularly tedious as it has multiple side

branches and lies adjacent to several important nerves. As arm veins are often relatively short, a

venovenostomy is often required to create composite grafts long enough to complete the arterial

reconstruction (Fig. 93.12). This is performed with generous spatulation of each vein hood to create a

widely patent vein-to-vein anastomosis. Given their thin-walled nature, arm vein grafts are also quite

prone to twisting and kinking, and special care must to taken during the tunneling process to avoid

these problems. The more proximal arm veins can be relatively large, and it is often advantageous to

use one or more of the segments in a nonreversed fashion to better match the graft to the inflow vessel

size.

2664

Figure 93-12. Creation of a composite graft from two or more segments of arm vein or lesser saphenous vein (A) is sometimes

necessary to obtain the desired length of fully autogenous conduit for infrainguinal bypass. A widely spatulated venovenostomy (B

and C) is optimal.

Not surprisingly, the results of reoperative infrainguinal bypass surgery do not match those of

primary reconstruction. With autogenous vein, 5-year patency rates of 60% and limb salvage rates of

70% to 80% have been reported.27,114 Coumadin is often used postoperatively in patients with

compromised outflow or in whom the conduit was of marginal quality and has been associated with

improved long-term patency.115

Postreconstruction Management

11 Many patients undergoing surgical reconstruction for critical ischemia with tissue loss require one or

more adjunctive operative procedures of their foot. Small, uninfected ulcerations of the toe or foot often

can be safely managed conservatively. However, larger, gangrenous lesions of the toe, forefoot, or heel

usually require débridement of all necrotic tissue at the completion of the revascularization procedure.

If the ischemia is particularly severe or infection is present, a toe or transmetatarsal amputation may be

necessary in order to achieve a margin of healthy tissue. This is particularly important in patients with

diabetes or end-stage renal disease, in whom persistent infection or necrosis can result in limb loss

despite the presence of a well-revascularized extremity. The wounds are usually left open and treated

with moist occlusive dressings or negative-pressure wound therapy. Serial débridements on the ward or

in the operating room are often necessary for the larger wounds, which can then be surgically closed

after an interval healing period or allowed to slowly close via secondary intention over time.

Unless otherwise contraindicated, all patients are maintained indefinitely on an antiplatelet regimen

with either aspirin or clopidogrel following surgical bypass. As stated previously, in cases in which a

graft is at increased risk of failure, such as in the setting of reoperation or in cases in which

compromised outflow or a marginal conduit was accepted, the antiplatelet agent may be supplemented

with heparin and then warfarin.115 Patients with distal calf or pedal incisions should have consistent leg

elevation in the early postoperative period to minimize leg swelling and wound healing complications.

Thereafter, aggressive rehabilitation maximizes the chances of, and shortens the time to a return to full

function after extensive reconstructive surgery. Ongoing risk factor modification in the form of smoking

cessation, lipid reduction, exercise, blood pressure management, and diabetic blood sugar control is of

further paramount importance in minimizing the risk of disease progression or recurrence.116

Graft Failure and Surveillance

Postoperative graft failures are typically classified according to the time interval from surgery as early,

intermediate, or late. Graft thrombosis occurring within 30 days, the so-called “early graft failures,” are

generally thought to be a result of technical or judgment errors by the surgeon. Included in this list

would be such technical errors as twists, kinks, incompletely lysed valves, or anastomotic defects, as

well as judgment errors in using a poor quality vein or targeting an outflow vessel with inadequate

runoff to support the graft. Intermediate graft failures include those between 30 days and 2 years and

are generally attributed to the proliferation of intimal hyperplasia at the anastomoses or prior valve

sites within the graft (Fig. 93-13). Late graft failures occurring beyond 2 years are typically a result of

the progression of atherosclerotic occlusive disease within the inflow or outflow arteries.

2665

Figure 93-13. Arteriogram demonstrating severe stenosis of distal graft from intimal hyperplasia, likely at prior valve site.

Given the known incidence of graft failure and the potentially dire consequence in terms of limb

salvage or preservation of limb function in a patient with limited options for secondary or tertiary

bypass, the ability to maintain graft patency through early identification and prompt correction of graft

stenosis is of paramount importance.117 Serial postoperative surveillance scanning with duplex

ultrasound has proven an excellent means of accurately identifying hemodynamically significant stenosis

within the vein graft that threaten the graft patency.118 Velocity criteria have been developed for highgrade lesions that may warrant either more intensive surveillance or prophylactic intervention. Absolute

velocities less than 40 cm/s or greater than 300 cm/s or a three-fold increase in velocity in one segment

compared with that of an adjacent segment are all indicative of impending graft failure. Confirmation

by angiography and expeditious treatment by percutaneous cutting balloon angioplasty, surgical patch

angioplasty, or interposition grafting of such significant lesions minimizes the risk of graft thrombosis

and ensures optimal long-term graft patency.

Complications

The most commonly seen major complications of infrainguinal bypass surgery are cardiac in nature, and

include myocardial infarction, congestive heart failure, and arrhythmias. In a recent review spanning 20

years and involving more than 1,600 procedures, the perioperative myocardial infarction rate was 3%,

and the rate of cerebrovascular accident was 1%.101 Patients with diabetes mellitus or preoperative

renal insufficiency are at particular risk for developing postoperative renal failure (defined as an

elevation of serum creatinine >3 mg/dL, doubling of the serum creatinine or the need for

hemodialysis), which is seen in up to 2% of patients overall. Patients undergoing lower extremity

revascularization are also prone to wound complications, given the length of incisions and the

prolonged operating times often required. Overall wound complications, including cellulitis and abscess

formation, wound dehiscence, and skin flap necrosis, can occur in up to 40% of patients and can best be

avoided by gentle handling of the tissue and the use of skin bridges and careful avoidance of skin flaps

during vein harvesting.119 Postoperative hematomas, usually caused by slow capillary or venous oozing,

or seromas are seen in 5% of patients; and less commonly encountered hemorrhage, typically a result of

either a slipped vein branch ligature or anastomotic disruption, is seen in less than 1% of cases.

ACKNOWLEDGMENT

This chapter is based on the previous version from the 5th edition entitled Femoropopliteal and Tibial

Occlusive Disease by William P. Robinson, Matthew T. Menard, and Michael Belkin.

2666

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