TEA of the femoral bifurcation, profunda patch plasty, dilatation and stent placement of the left superficial femoral artery

Longitudinal skin incision approximately 1 cm lateral to the palpable femoral artery. Division of the subcutaneous fatty tissue and exposure of the thigh fascia, which is incised medial to the sartorius muscle. Circumferential dissection and slinging of the superficial femoral artery, then division of the lateral lymphatic collectors under the inguinal ligament, which are secured with transfixion ligatures.

Tips:

1. The access approximately 1 cm lateral to the artery spares the lymphatic collectors and allows a later curtain-like wound closure with the aim of better wound healing.

2.  Transfixion ligatures of the lymphatic collectors help to largely avoid later lymphocysts or lymph fistulas. Lymph accumulations in the groin often pave the way for a deep wound infection, especially in stage IV of PAOD, which endangers the extremity or even the life of the patient. Simple ligatures tend to slip off later!

Preparation, encircling and looping of the common femoral artery. Crossing veins over the deep femoral artery are transected and secured with transfixion ligatures. Exposure and looping of the dorsally originating medial circumflex femoral artery. The deep femoral artery is prepared beyond the palpable calcification, at least up to the third branch. Looping of the deep femoral artery peripherally in a soft segment.

Tips:

1. For the management of the crossing veins over the deep femoral artery, transfixion ligatures are preferred to avoid slippage of the ligatures, which can lead to intra- or postoperative bleeding.

2. The deep femoral artery must be prepared for a profundaplasty at least up to the third branch, because otherwise - experimentally proven – an improved inflow cannot be achieved. Too short profundaplasties are insufficient!

Clamping of the femoral bifurcation centrally and peripherally and management of the collateral branches with bulldog clamps. Incision of the common femoral artery using a scalpel and extension of the incision with Potts scissors into the deep femoral artery beyond the palpable calcifications. Instillation of a total of 6000 IU heparin-saline solution centrally and peripherally into all branches.

Tip:

Always test inflow and backflow!

Using a vascular spatula, locate a suitable dissection plane (either close to the intima or adventitia) and perform the TEA. Centrally, after crushing at the upper atherosclerosis boundary (Pässler method), extraction of the intima cylinder. Peripherally, perform the TEA preferably without a peripheral step.

Tip:

In the TEA, preferably leave a suturable residual wall!

Insertion of a 7F sheath into the superficial femoral artery. Orienting angiography for the preparation of the AFS dilatation.