Femoropopliteal Bypass
Kenneth B. Simon
A variety of conduits have been used to bypass obstructed segments of the femoropopliteal system. Autogenous saphenous vein is the graft preferred by most surgeons. The saphenous vein may be removed completely from the contralateral leg, as described in Chapter 107, and used in a reversed fashion. Alternatively, an in situ bypass may be performed. In this chapter, the technique of in situ saphenous vein bypass is described.
Steps in Procedure
Mildly externally rotate leg, flex and elevate at level of knee
Longitudinal incision over femoral artery (from 2 to 3 cm above inguinal ligament to 10 cm below inguinal ligament)
Identify and dissect common femoral, profunda femoris, and superficial femoral artery
Ligate and divide small venous branch crossing profunda femoris artery
Obtain proximal control of common femoral artery and distal control of both superficial femoral and profunda femoris arteries
Identify greater saphenous vein and its branches
Exposure of Proximal Popliteal Artery
A 4- to 5-cm longitudinal incision 1 cm proximal and inferior to adductor tubercle
Retract sartorius muscle posteriorly and tendons of other muscles anteriorly
Identify popliteal artery and vein along posterior medial borders of femur
Secure branches of venous plexus
Exposure of Distal Popliteal Artery
Longitudinal incision about 7 to 10 cm long, 1 cm posterior to tibia and 1 to 2 cm distal to medial femoral condyle
Incise deep fascia and retract soleus and gastrocnemius to expose distal popliteal artery and vein
Prepare vein by passing valvulotome retrograde
Create proximal and distal anastomoses
Perform an on-table arteriogram to identify any arteriovenous fistulae
Alternatively, seek these using Doppler ultrasound probe
Irrigate wounds, obtain hemostasis, and close
Hallmark Anatomic Complications
Occlusion of bypass (retained valves)
Arteriovenous fistulae
Lymphocele
Injury to saphenous nerve
List of Structures
Inguinal ligament
Pubic tubercle
Anterosuperior iliac spine
Femur
Medial femoral condyle
Superficial circumflex iliac artery and vein
Superficial epigastric artery
Superficial external pudendal artery and vein
Inguinal lymph nodes
Femoral sheath
Fascia lata
Femoral Artery
Superficial femoral artery
Popliteal Artery
Superior medial genicular artery
Superior lateral genicular artery
Middle genicular artery
Anterior tibial artery
Posterior tibial artery
Peroneal artery
Profunda Femoris Artery
Medial circumflex femoral artery
Lateral circumflex femoral artery
Femoral Vein
Greater saphenous vein
Lesser saphenous vein
Femoral nerve
Saphenous nerve
Peroneal nerve
Saphenous hiatus (fossa ovalis)
Inguinal lymph nodes
Iliopsoas muscle
Pectineus muscle
Adductor brevis muscle
Adductor longus muscle
Adductor magnus muscle
Adductor tubercle
Adductor canal
Sartorius muscle
Semimembranosus muscle
Semitendinosus muscle
Vastus medialis muscle
Popliteal fossa (space)
Soleus muscle
Calcaneal tendon
Gastrocnemius muscle
Sites of Groin Incision (Fig. 108.1)
Technical Points
Place the patient supine on the operating table with the thigh mildly externally rotated, flexed, and elevated at the level of the knee joint. Palpate the inguinal ligament and identify the pubic tubercle and anterosuperior iliac spine. Place a longitudinal skin incision centered over the femoral artery (Fig. 108.1A). This skin incision should extend from 1 to 2 cm above the inguinal ligament to about 10 cm below the inguinal ligament. The profunda femoris artery usually takes off from the common femoral artery at the level of the inguinal ligament or about 1 to 3 cm distal to it. The skin incision must, therefore, extend above the inguinal ligament to expose the common femoral artery adequately. If the incision or dissection is below the usual anatomic bifurcation of the common femoral artery, only the superficial femoral artery will be seen.
Several lymph nodes will be found anterior to the femoral artery in the femoral canal (Fig. 108.1B). Be careful to avoid injury to the lymphatic channels and lymph nodes in this area. Disruption of the lymphatic system can result in lymphorrhea, lymphocele formation, or wound problems. Dissect the common femoral, profunda femoris, and superficial femoral arteries gently. A small venous branch courses over the profunda femoris artery. Ligate and divide this vein to allow access to the profunda femoris distal to its first perforating branch. Obtain proximal control of the common femoral artery and distal control of both the superficial femoral and profunda femoris arteries using Silastic loops.
The greater saphenous vein is superficial and medial to the common femoral artery. The groin incision diagrammed allows for excellent exposure of the saphenous vein. Either continuous or interrupted skin incisions may be used to perform an in situ bypass.
Anatomic Points
The common femoral artery is the most lateral structure in the femoral sheath. It reliably bisects the inguinal ligament. This relationship can be used to locate the femoral artery, even when occlusive disease prevents location of a palpable pulse. The femoral nerve lies immediately lateral to the femoral artery, whereas the femoral vein is immediately medial to the artery.
Exposure of the femoral artery demands dissection through the superficial fascia, fascia lata, and femoral sheath. The superficial fascia in this region contains the superficial circumflex iliac vessels, the superficial epigastric vessels, and the superficial external pudendal vessels. The arteries, which are branches of the (common) femoral artery, all pass through the cribriform fascia of the saphenous hiatus, or penetrate the fascia lata adjacent to the hiatus, to gain access to the superficial fascia. Typically, the veins are tributaries of the greater saphenous vein and either join this vein before its passage through the cribriform fascia or pass through the cribriform fascia independently, draining into the saphenous vein just before it empties into the femoral vein.
The largest vascular structure in the superficial fascia is the greater saphenous vein, which essentially overlies the proximal femoral vein and is thus medial to the femoral artery axis. In its course in the upper thigh, it lies between two layers of superficial fascia and is, therefore, not as obvious as it is in the lower leg. In addition to receiving the small tributaries mentioned earlier, typically, one or more larger tributaries draining the thigh or communicating with the lesser saphenous vein also drain into the greater saphenous vein.
In addition to these arteries and veins, several superficial inguinal lymph nodes are found in this area. These constitute two groups: horizontal and vertical nodes. The horizontal nodes (which drain the lower trunk) and their vessels parallel the inguinal ligament and are just inferior to the ligament. The vertical nodes, which drain the inferior extremity, lie in the superficial fascia over the femoral artery. Efferents from these nodes pass through the cribriform fascia and drain into nodes closely associated with the femoral canal, a space in the femoral sheath just medial to the femoral vein through which the lymphatics pass to drain into iliac nodes.
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