Femoropopliteal bypass on the right with PTFE prosthesis (PIII)

Approximately 1 cm lateral to the palpable femoral artery, make a longitudinal skin incision on the proximal thigh distal to the inguinal region. After transecting the subcutaneous tissue, incise the femoral fascia longitudinally medial to the sartorius muscle. At the caudal edge of the incision, open the fascia of the adductor canal, expose the superficial femoral artery and encircle it with a vessel loop. Divide the lymph collectors crossing beneath the inguinal ligament between Overholt clamps and secure them with transfixion ligatures. The lymph nodes are enlarged owing to PAOD Fontaine grade IV.

Tips:

1. Access lateral to the femoral artery spares the lymph collectors and permits subsequent offset layered closure to promote reliable wound healing.

2. The superficial femoral artery serves as a landmark for proximal dissection lateral to it. This makes it easy to locate the deep femoral artery and the common femoral artery, and also avoids the risk of injury to the veins running medially.

3. Transfixion ligation of the lymph collectors helps to largely prevent subsequent lymphatic cysts and lymphatic fistulae. Postoperative inguinal lymph collection in PAOD grade IV not infrequently paves the way for a deep wound infection with fatal consequences for the limb and possibly even for the patient's life.

Dissection is carried out along the superficial femoral artery proximally to expose the common femoral artery, which is encircled with a vessel loop. Expose the deep femoral artery and the medial and lateral circumflex femoral arteries. Encircle the vessels and place a moist gauze pad.

Access to the first segment of the popliteal artery is achieved through a skin incision above the knee joint on the medial thigh (transition from the middle to the distal third of the thigh width). After transecting the subcutaneous tissue, the femoral fascia is incised longitudinally anterior (ventral) to the sartorius muscle and the muscle is retracted posteriorly. Insert a retractor (e.g., a van Dongen retractor). The vascular bundle is located at the inferior margin of the adductor canal, the popliteal fat pad is incised and the popliteal artery is exposed in its first segment. Any crossing veins are transected between ligatures during dissection. After encircling the popliteal artery, it is clamped.

Contrary to the preoperative angiogram, the severely arteriosclerotically stenosed popliteal artery is thrombotically occluded in segments 1 to 2. The thrombus is already beginning to organise and adheres to the wall. Therefore, the attempted thrombectomy with the Fogarty catheter via the longitudinally incised popliteal artery is unsuccessful. The popliteal artery is ligated proximal and distal to the arteriotomy (not shown in the video).