Femoro-Popliteal/Distal Bypass Surgery (Vein)

Step 1: Exposure

1. Exposure the femoral bifurcation
2. Placement of vessel loops around common femoral artery (CFA), superficial femoral artery (SFA) and deep femoral artery (DFA)
3. Apply heparin and clamp the CFA, SFA and DFA
4. Expose the below knee 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 arteriotomy from the SFA (or it's stump) into the CFA
2. Endarterectomy of distal CFA (if necessary)
3. Obliquetrimming of the proximal end of the vein
4. Parachute technique of the anastomosis, 5-0 polypropylene running suture
5. Suture starts on the opposite site
6. Direction of stitches: vein to be sutured from outside-in, CFA to be sutured from inside-out
7. Running suture, use always the same needle all around
8. Flush and clamp the proximal vein, allow reperfusion of the DFA

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

1. Longitudinal incision in PA III/crural artery, control of back bleeding using a soft clamp, a balloon or a double loop, rinse locally with heparin
2. Round of edges with 3.5 mm punch if available
3. Longitudinal incision in distal end of vein graft
   • Perform end-to-side anastomosis in parachute and running suture technique
   • Direction of stitch: vein to be sutured from outside-in, artery to be sutured from inside-out
   • Running suture, no change of direction or needle required
   • In small caliber vessels use interrupted suture technique
4. Flush and clampthe proximal vein, then flush from distal and allow reperfusion
5. 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. Transect popliteal/crural artery
2. Control backflow
3. Interrupted stitches 6-0 polypropylene suture, first back wall, second front wall
4. Optional: back wall running suture, front wall interrupted stitches
5. Flush and remove clamps
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 of anastomoses (outside and 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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