The Procedure / Femoral Popliteal Bypass | Femoral Popliteal Bypass Surgery

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The Procedure

Grafts

As the procedure intends on bypassing the affected area of artery which is being blocked between the Femoral and Popliteal artery, the surgeon must decide what is going to be used as the new conduit.

There are two options which can be selected. First is the is an autologous vein harvest, commonly the greater saphenous vein Nierlich et al. (2019) which is taken from the patient themselves but can be unsuitable for grafting in upto 45% of cases.

The second is a prosthetic graft made out of Dacron or Polytetrafluoroethylene (PTFE), these grafts tend to be used as an alternative to a vein harvest when the vein is unsuitable. However Sharrock et al. (2019) suggests that a harvested graft has a better patency rate compared to a synthetic one, this is supported by Mlees et al. (2020) who suggest the appropriate choice should be an autologous graft.

Use the WHO to discover what approach the surgeon is going to take, this will allow you to ensure you have the correct graft if a synthetic one is needed.

Image:(Coyle, 2016)

Femoral cut down and Vein identification

If using the autologous vein Darling and Ozaki. (2015) suggest exposing the vein should be the start of the procedure, allowing for early identification on the suitability and length of the vein for grafting.

Once identified the surgeons will then move onto exposing the common femoral artery beginning with an incision in the groin and using blunt and sharp dissection to expose the artery. Once Identified and fully dissected the surgeon will use vessel loops to isolate and control the structure of the artery (Hauk, 2018).

Be aware in some cases there may be multiple surgeons working on the femoral cutdown, vein harvest and popliteal cutdown at the same time!

Image:(Velmahos et al, 2019)

Video:(Fatih Yuvacı, 2022)

Popliteal artery exposure and tunneling a passage.

Two locations can utilised when exposing the popliteal artery, the first is in the lower thigh (Proximal end) and the second is below the knee (Distal end) the distal end would normally be exposed if the proximal end is affected by disease. Exposed and dissected in a similar manner as the femoral artery the surgeon will again use vessel loops to isolate and control the artery (Darling and Ozaki. 2015),(Hauk,2018).

Once exposed a connection needs to be made in the anatomy of the patient between the femoral and popliteal artery’s this is called tunnelling. This anatomic tunnelling aims to protect the graft from damage and kinks Darling and Ozaki. (2015) this process can be completed with a vascular tunnelling device (Moutrey, 2018)

Image:(Anesthesia Key, 2020)

Video:(Video Atlas of Open Vascular Surgery, 2023)

Vein Harvest

Once all vessels have been appropriately exposed and dissected the graft can be harvested from the patient. This process begins with the clamping of the distal end of the graft and ligation of the proximal end as the distal end is wider. A cannula is inserted attached to heparinised saline this will allow for manipulation of the vessel and identification of any damage. (Darling and Ozaki, 2015).

Image:(TCTMD, 2019)

Video:(SBK, 2020)

Anastomosis of the graft

The last major step in this procedure is the anastomosis of the graft to the non-diseased section of the arteries. Clamping each section of artery and making an incision, from there the graft is sutured to the artery, this is done with prolene sutures 5-0 – 7-0. (Darling and Ozaki, 2015) Once attached the clamps are gradually released to assess the patency of the anastomosis.

Unknown image author

Video:(Methodist, 2021)

After successful implantation of the graft the surgeon will proceed to close all of the incisions. THIS IS THE OPPORTUNITY TO CALL FOR A PAUSE TO COUNT YOU'RE INSTRUMENTS AND CONSUMABLES! Especially if you are working with more than one surgeon.

Be aware that complications can occur after surgery in the recovery room. Patients are held here to be observed immediately after surgery and is often the first place where postoperative complications may arise (Craig and Hatfield, 2021). If a complication occurs the patient may need further surgical intervention to rectify the issue. You may have to prepare the theatre for the return of that patient.