Femoro-popliteal supragenicular bypass (prosthesis)

Access

1. Cut down to femoral bifurcation
2. Put vessel loops around common, deep and superficial femoral arteries
3. Apply heparin and clamp the common femoral (horizontally!) and deep femoral arteries (soft clamp i.e. Yasargil clamp, or double loops)

Proximal anastomosis (side-to-end)

1. Longitudinal arteriotomy from ostium of superficial femoral artery into common femoral artery, perform TEA if necessary
2. Oblique and curved tailoring of the prosthesis (6mm-8mm Dacron or PTFE) to enable a 30° take off of bypass (end-to-side)
3. Perform anastomosis in parachute and running suture technique
4. Start suturing on your far (= your assistant's) side
5. Direction of the stitches: prosthesis to be sutured from outside in, artery to be sutured from inside out
6. Running suture, no change of direction or needle needed
7. Flush and clamp prosthesis proximally, release clamp on common and deep femoral arteries to reinstall perfusion into deep femoral artery circulation

Distal anastomosis (end-to-end)

1. Cut down to popliteal artery pars I (above knee)
2. Clamp and transsect the distal superficial femoral artery/proximal popliteal artery
3. Longitudinal arteriotomy into popliteal artery, with control of back bleeding using a clamp or a balloon, rinse locally with heparin
4. Oblique and curved tailoring of vascular prosthesis (6mm-8mmDacron or PTFE)
5. Perform an end-to-end anastomosis in parachute and running suture technique
6. Direction of stitches: prosthesis to be sutured from outside in, artery to be sutured from inside out
7. Running suture, no change of direction or needle required
8. Flush and clamp prosthesis, release clamp on popliteal artery for back bleeding/flushing, tie anastomosis and allow reperfusion

Control of learning targets

• Incision line on CFA, SFA and PA, tailoring of prosthesis
• Sequence of single steps
• Length of anastomosis (2 to 2.5 times diameter)
• Stitch distance, tightness of suture
• Everting anastomotic technique