Peripheral Surgery: Femoro-Popliteal/Distal Bypass Surgery (Vein)

Step 1: Exposure

1. Exposure of femoral bifurcation
2. Placement of vessel loops around common femoral artery (CFA), superficial femoral artery (SFA) and deep femoral artery (DFA)
3. Clamping of CFA and DFA
4. Ligation of SFA
5. Exposure of the infragenual popliteal artery Pars III or one of the crural arteries (anterior tibial artery, posterior tibial artery, peroneal artery)

Step 2: Proximal anastomosis (CFA – vein side-to-end)

1. Longitudinal incision from the stump of the SFA into the CFA
2. Endarterectomy of distal CFA (if necessary)
3. Oblique transection of the proximal end of the vein
4. Parachute technique of the anastomosis, 5-0 polypropylene suture, running suture
5. Suture starts on the opposite site
6. Stitch direction: vein outside-in, CFA inside-out
7. Running suture, use always the same needle
8. Flushing and clamping of the proximal vein, reestablishment of blood flow in the DFA

Step 3: Distal anastomosis (vein-artery; side-to-end)

1. Longitudinal incision of the infragenual popliteal/crural artery, control of back flow
2. Rounding of edges with 3.5 mm punch
3. Longitudinal incision of the distal end of the vein graft
4. Parachute technique of the anastomosis, 6-0 polypropylene suture, running suture
   1. suture starts on the opposite site
   2. stitch direction: prosthesis/vein outside-in, popliteal/crural artery inside-out
   3. running suture, use always the same needle
5. Flushing
6. Angiography of the vein bypass; assessment of anastomosis and outflow, transit time flow measurement, measurement of resistance index

Step 4: Distal anastomosis (vein-artery; end-to-end; distally to complete occlusion)

1. Transection of popliteal/crural artery
2. Backflow control
3. Interrupted stitches 6-0 polypropylene suture, first back wall, second front wall
4. Optional: back wall running suture, front wall interrupted stitches
5. Flushing
6. Angiography of the vein bypass; assessment of anastomosis and outflow, transit time flow measurement, measurement of resistance index

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Control of educational objectives (tutor and trainee)

Assessment ofanastomoses (outsideand inside aspect)

• Incision CFA, distal artery, vein graft
• No excessive bleeding after completion
• Knot and suture tightness
• Suture distances
• Length of the anastomosis
• Eversion

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