Some time in case of extensive PAD and critical ischemia we need to perform the simultaneous reconstruction of aorto-iliac and femoral-popliteal segment. What is your opinion about the optimal site of proximal anastomosis for femoral-poplieal bypass with reversed saphenous vein? Should vein takes-off from the synthetic graft or from the common femoral (femoral) artery? Some surgeons claimed against the anastomosis between synthetic material and vein.
Hi,
I think there is no universal answer. Should the aorto-femoral graft need to go down to profunda femoris, than it is morphologically suitable to have the proximal anastomosis put on the side of this graft. I would also consider even not using a saphenous vein but use a Propaten (Gore heparin bounded graft) graft for distal revascularisation. This would significantly shorten the operation time (those patients who need this extensive operations have a short life expectancy and usually very sick with comorbidities). There is already prosthetic material in the groin, so the risk of graft infection already exists. In summary: these patients need individual decision making and possibly improvisation at the time of surgery.
Regards
Z A Varga
I favored to anastomose the aorto-femoral graft limb end-to-side to the common femoral artery with a tongue extending for about 1-2 cm in the profunda femoris artery, and the venous bypass (preferentially over non-autologous graft) end-to-side implanted in the graft limb. I used to implant a venous patch in the graft limb for anastomosis with the vein graft in case the vein graft appeared rather small (< 4 mm in diameter). In skinny patients and patients in whom skin healing might be jeopardized (for instance a redo) I would cover the graft and its anastomic area with a sartorial muscle flap over which the skin is closed with an continuous intracutaneous absorbable suture.
Dear Dr. Varga, Dear Dr. Bruijninckx!
Thank you a lot for you wise opinions.
I usually make proximal anastomosis of the fem-pop vein bypass at the common femoral artery not at the prosthetic graft. If common femoral anastomosis is unavailable, I make the anastomosis at the proximal profunda femoris.
Nice! We have new opinion! Thank you for answer my question Dr. Kim. Can you also explain the reasons why you avoid the anastomosis between the vein and graft? My personal approach is not standard, but I also try to avoid the connection between the Dacron and vein if it is possible. If at least 5-10 mm of SFA is relative free of atherosclerotic process I prefer to construct the end-to-end anastomosis between the vein and SFA. Not rare it requires eversion endarterectomy from the SFA stump.
Dear Dumitru,
I leave this to the arterial experts - as you know I'm only into venous...
Kind regards,
Marianne
When doing in situ vein bypass, I prefer to make the proximal anastomosis to SFA after eversion endarterectomy.
For reversed vein graft, I prefer the graft.
I think there is no reasonable explanation to avoid graft and vein anastomosis.
If it is a vein graft, better to plug it in to the distal CFA, or to the profunda. If you plug it in to the AF graft limb, you will likely lose the FP vein graft when the graft limb goes down. Or follow Dr. Casian's suggestion.
Profunda femoris or proximal superficial. Side-to end anastomosis: cutting superficial femoral in order to perform end-to end anastomosis could preclude future endovascular solutions.
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