Aortofemoral bifurcation bypass (bifurcated graft) for peripheral arterial occlusive disease stage IIb–III

Longitudinal skin incision about 1 cm lateral to the femoral artery and transection of the subcutis with meticulous haemostasis. While sparing the lymphatics, divide the lateral lymph collectors immediately caudal to the groin between clamps and secure them with transfixion ligatures. Dissect and loop the common femoral artery, superficial femoral artery, and deep femoral artery. Palpate the vessel wall (quality, calcification).

Tips:

1. The first step is to expose the groin so that the abdominal cavity remains open only for a short time. As a result, the patient cools down less quickly, which improves the postoperative phase and allows for faster extubation.

2. Access lateral to the femoral artery allows a staggered closure of the groin. This better secures the vascular reconstruction, and superficial wound healing disorders, such as wound margin necrosis, do not necessarily result in a deep infection.

3. Especially in Fontaine stage IV PAOD, the lymph collectors and lymph nodes are often markedly enlarged and represent a potential source of infection for the vascular reconstruction. Careful instrumental dissection is therefore imperative, with no crude manipulation of the wound with the fingers!

4. The medial circumflex femoral artery lies mediodorsally (femoral artery -> deep femoral artery -> medial circumflex femoral artery). Its location and caliber vary greatly and it is often of large caliber. It must be looped separately and clamped off later, since injuries to this vessel can lead to bleeding that is difficult to manage.

5. In Fontaine stage IV PAOD, as well as in repeat procedures, pronounced adhesions between the femoral artery and the deep femoral vein are usually present. In these cases, time-consuming dissection is to be expected.

After cross-clamping and longitudinal incision of the femoral bifurcation, instil 2000 IU of heparinised saline locally, proximally into the femoral artery and distally into the superficial and deep femoral arteries. Identify a suitable dissection plane and perform the local TEA.

After inserting a moist gauze swab (secured with traction) and covering the groin wound with a moist abdominal towel, carry out the same procedure in the left groin (not illustrated).

Tips:

1. Do not provoke distal dissection.

2. Ensure adequate distal exposure into a soft segment of the artery.

3. If necessary, suture-fixate a plaque that does not taper off distally.

4. If necessary, plan for a profundaplasty, which requires exposure to the 3rd division of the vessel.

5. If, following the TEA of the inguinal vessels, the vessel wall is thin and fragile and the vascular suture cuts through easily, a trick can be used to salvage the situation. For this purpose, dissect a strip of fascia from the thigh musculature and hold it against the outside of the vessel wall as a counter-pledget for stabilisation, incorporating it into the vascular suture. This not only prevents the suture from tearing through from the outset, but also allows an already torn vessel wall to be repaired.

Perform a median laparotomy from the xiphoid down to the symphysis, incising around the navel on the left side.

Tips:

1. Maintain adequate distance from the navel and do not incise the skin tangentially, as this may otherwise result in wound edge necrosis.

2. If the incision injures the cartilage of the xiphoid, this can lead to the development of a so-called scar bone (heterotopic ossification). The incision should therefore begin slightly lateral to the xiphoid.

After exploring the abdomen, displace the transverse colon into the upper abdomen and eventrate the small intestine. Open the retroperitoneum slightly lateral to the right, over the palpable aorta and the right iliac axis, while protecting the inferior mesenteric artery (IMA).

Prepare the tunnels for the later pulling-through of the graft limbs by blunt digital dissection. On the right, the finger of the left hand is orientated lateral to the inferior vena cava on the iliopsoas muscle, on the left on the back of the iliac artery. On both sides, tunnelling is carried out posterior to the ureter (incorrectly placed graft limbs may lead to ureteral stenoses). From the groins, the finger of the right hand tunnels posterior to the respective inguinal ligament. The tunnelling fingers of both hands should meet in the retroperitoneum.

Tips:

1. The more pronounced the stenoses of the aorta and iliac axis are, the more strongly developed are the collaterals in the retroperitoneum, and they cause bleeding when severed, which should be stopped immediately.

2. The aorta is exposed up to the crossing left renal vein, because in most cases a segment suitable for cross-clamping will only be found there.