Femoropopliteal Bypass

CHAPTER 26 Femoropopliteal Bypass


Peripheral arterial disease (PAD) is a common but underdiagnosed and undertreated disorder that affects 8 to 10 million Americans and an estimated 20% of the general population older than 55 years of age. The prevalence of PAD increases with age and in the presence of cardiovascular risk factors, such as diabetes, hypertension, smoking history, dyslipidemia, and hyperhomocysteinemia.

Intermittent claudication (IC) is defined as reproducible lower extremity pain on exertion that is caused by inadequate blood flow and is reliably relieved by rest. Classic IC occurs in only 30% of patients with symptomatic PAD, and many older patients with PAD instead complain of lower extremity fatigue, difficulty with ambulation, or other leg discomfort atypical of claudication. A thorough history and physical examination, as well as noninvasive vascular laboratory studies, will usually differentiate IC from other common diagnoses, such as arthritis, nerve root compression, and venous congestion.

Lower extremity PAD is typically classified as aortoiliac, femoropopliteal, or tibial in distribution. Symptoms frequently correspond to the level of occlusive disease and are localized to muscle groups one joint level below the region of occlusion; calf muscle claudication is most commonly due to superficial femoral artery occlusion, and hip, thigh, or buttock claudication is most commonly due to proximal aortoiliac disease. Multilevel disease can produce symptoms at any level. Importantly, calf claudication is the most common presenting symptom in patients with femoropopliteal disease and in those with occlusive aortoiliac disease because of the distal extent of this muscle group.

Patients with PAD often have concomitant comorbidities. Nearly one third of patients with IC die within 5 years of diagnosis of myocardial infarction, cerebrovascular disease, or other cardiovascular events, a rate more than three times that in age-matched control subjects. Based on the presence of risk factors, the global nature of atherosclerotic disease, and the high risk of systemic ischemic events, patients with PAD should be treated with aggressive lifestyle modification, appropriate pharmacotherapy, and when necessary, appropriate intervention.

Interventions for lower extremity PAD range from percutaneous procedures, such as angioplasty, stenting, or atherectomy, to operative bypass. Operative bypass is usually reserved for circumstances in which percutaneous procedures are unsuccessful or cannot be performed because of anatomic factors. Infrainguinal bypass refers to any major arterial reconstruction that originates below the inguinal ligament and uses a graft (i.e., autogenous vein, cadaveric vein, or prosthetic conduit such as polytetrafluoroethylene [PTFE]). Proximal inflow sites include the common, superficial, and deep femoral arteries, and target sites include the popliteal (above or below the knee), tibial, peroneal, and pedal arteries. This chapter focuses on femoropopliteal bypass for the treatment of PAD and IC.



The clinical diagnosis of lower extremity ischemia should be confirmed with a thorough physical examination and a noninvasive arterial evaluation. Radiographic imaging of the arterial anatomy should be obtained when an intervention is planned.

II. Noninvasive Diagnostic Evaluation

Stay updated, free articles. Join our Telegram channel

May 26, 2018 | Posted by in GENERAL SURGERY | Comments Off on Femoropopliteal Bypass

Full access? Get Clinical Tree

Get Clinical Tree app for offline access