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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3749_Библиотеки_им_академика_М_И_Перельмана
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302
2. Hostile abdomen.
3. Adjunct to aorto-uni-iliac (AUI) stent graft for repair of abdominal aortic
aneurysm.
4. Absence of endovascular options for iliac occlusive disease.
A. Lee
Procedure
Groin incisions are made in longitudinal fashion. It is helpful to use an ultrasound
to mark the bifurcation prior to prepping. Dissect out and obtain control of the common femoral, supercial femoral, and profunda arteries. An endarterectomy may be
needed depending on plaque burden/disease. A suprapubic subcutaneous tunnel
anterior to the abdominal fascia is made in reverse C shape. This can be created with
blunt dissection using ngers, a tunneling device, or a curved aortic clamp. Pass the
graft (usually 8 mm PTFE with rings) using a tunneling device or a long aortic
clamp. Heparinize for an ACT >250. If intervention is needed of the donor iliac, this
should be completed. Donor anastomosis will be made in end-to-side fashion using
5-0 prolene. Prior to completion of anastomosis, artery should be forward and backbled. The distal anastomosis is also completed in end-to-side fashion using 5-0
prolene, and prior to completion of anastomosis, the artery and graft should be
ushed. Close the groins in multiple layers and take care to avoid compression/
kinking of the graft. Pay particular attention to not leave a dead space which can
lead to seroma formation and possible infection.
Diagrams oftheProcedure
“Course/tunneling of femoral-femoral bypass with anastomosis over the origin of
the profunda artery and origin of the supercial femoral artery” (see Fig.29.1).
Pearls andComplications
1. Donor iliac needs to be free of disease and may need endovascular intervention.
2. When creating the tunnel, the “turn” of the graft should be several centimeters
superior to the planned arteriotomy site to reduce kinking. Kinking commonly
occurs at the heel if the “turn” is too steep or shallow.
3. A small amount of redundancy in the graft can decrease kinking of the graft at
the heel.
Crossover fem
Crossover fem-fem bypass graft
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29 Crossover Femoral-Femoral Bypass Graft andIliofemoral Bypass Graft
Fig. 29.1 Anastomosis of
crossover femoral-femoral
graft to the femoral artery
is performed via
subcutaneous suprapubic
tunnel
fem graft
303
Subcutaneous
suprapubic
tunnel
4. If patient is high risk for general anesthesia, local anesthesia or epidural is
an option.
5. If a subcutaneous tunnel is contraindicated, a tunnel can be made in the preperi-
toneal position but be wary of a bowel or bladder injury with tunneling.
304
A. Lee
Iliofemoral Bypass
Anatomy
See fem-fem bypass section.
Indications
See fem-fem bypass section.
Procedure
Groin Exposure
Groin incision can be made in longitudinal or transverse fashion. Obtain control of
the common femoral, supercial femoral, and profunda arteries. If the profunda
artery is the only patent target, ligate venous branches to ensure adequate exposure
of the profunda. A profundaplasty may also be needed if there is heavy disease.
Iliac Exposure
A. Intraperitoneal Approach
A low midline incision is made. Place a self-retracting system to improve
exposure. Retract the bowel to the right side. This will expose the aorta/iliac
artery. Open the posterior peritoneum over the aorta and extend caudally. Very
important to identify the ureter and retract lateral. Obtain control of common
iliac artery and take care to avoid injury to the iliac vein that is located
posteriorly.
B. Retroperitoneal Approach
Patient is placed supine with placement of a roll under the ipsilateral hip. The
start of the incision is made from the midaxillary line halfway between the subcostal margin and iliac crest. The distal end of the incision should be 3cm above
the inguinal ligament at the lateral border of the rectus. The incision is oblique
and there can be a slight curve. Divide external oblique aponeurosis in the direction of its bers. Then the internal oblique and transversus abdominal muscles
are divided in the line of the incision. Enter the retroperitoneum. Open the retroperitoneal space and retract the peritoneal sac and ureter medially. The common iliac artery will be just medial to the iliopsoas muscle.
i
Ilio-femoral
29 Crossover Femoral-Femoral Bypass Graft andIliofemoral Bypass Graft
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305
Procedure
Create a tunnel using blunt dissection in the plane anterior to the iliac artery so that
the ureter will be posterior to the graft. Be sure to tunnel underneath the inguinal
ligament. Use an umbilical tape to mark the tunnel, then pass a Dacron or ringed
PTFE graft (usually 8mm) through the tunnel. Heparinize to achieve an ACT >250.
Clamp the iliac artery and then create a longitudinal arteriotomy about 1.5cm. Sew
an end to side anastomosis using 5-0 prolene. Prior to completing the anastomosis,
the artery and graft are ushed. Repeat for the distal anastomosis, end-to-side with
5-0 prolene. Close each muscle layer in the ank separately (generally interrupted
sutures for transversus/internal oblique and continuous suture for external oblique
aponeurosis) using 0 Vicryl. Close the groin in multiple layers.
Diagrams oftheProcedure
“Course of ileofemoral bypass” (see Fig.29.2).
Fig. 29.2 Ileofemoral
bypass course and anatomy
Common il
Psoas maj
D.F.A.
S.F.A.
306
A. Lee
Pearls andComplications
1. Minimize dissection of left common iliac artery to preserve the autonomic nerve
bers (postoperative sexual dysfunction in male patients).
2. If the external iliac artery is needed for the bypass, an incision 2cm above and
parallel to the inguinal ligament is made.
Chapter 30
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Axillo-Femoral Bypass
AliceLee
Anatomy
The axillary artery consists of three parts. The rst portion is distal to the lateral
border of the rst ribto the medial edge of the pectoralis minor. The superior thoracic artery arises in this section. The second portion is under the pectoralis minor.
The rst branch is the thoracoacromial trunk which divides into the acromial artery,
pectoral artery, clavicular artery, and deltoid artery. The second branch is the lateral
thoracic artery.The third portionof the arteryis from the lateral edge of the pectoralis minor to the lateral border of teres minor. There are three branches which are
the subscapular artery, anterior humeral circumex artery, and posterior humeral
circumex artery. The vein lays medial to the artery.
Indications
1. Hostile abdomen
2. Abdominal infection
3. Poor surgical candidate due to comorbidities
A. Lee (*)
Henry Ford Hospital, Detroit, MI, USA
e-mail: alee18@hfhs.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
S. S. Hans et al. (eds.), Primary and Repeat Arterial Reconstructions,
https://doi.org/10.1007/978-3-031-13897-3_30
307
308
A. Lee
Procedure
The donor arm is abducted 90 degrees and a towel roll is placed under the patient.A
10–12cm transverse incision about one nger breath below the middle third of the
clavicle is made (from the costosternal junction to the deltopectoral groove). Incise
the pectoralis major fascia along the direction of its bers. Usually the medial portion of the pectoralis minor muscle is divided to help mobilize the axillary artery or
the muscle is retracted laterally. The axillary vein is anterior and caudal to the
arteryand may need to be isolated to improve exposure of the artery. Avoid injury
to the cords of the brachial plexus that lay superior and posterior to the artery.
Dissect out 4–5cm of the axillary artery. Next an incision is made in the groin, and
the common femoral, profunda, and supercial femoral artery is mobilized. The
proximal graft is generally under the pectoralis minor muscle but can be placed on
the anterior surface. A subpectoral muscle is created parallel to the axillary artery
and continued in a subcutaneous plane in the axilla. The tunnel continues distally
along the anterior axillary line and will gently curve at the level of the anterior superior iliac spine towards the groin.A counter incision made belowthe costal marginwill help with tunneling. Next, an 8 mm-ringed PTFE is passed through the
tunnel. If a femoral-femoral crossover graft is planned, the tunnel should be created
next. A prefabricated graft for an axillobifemoral bypass can be used for this.Be
sure to allow slight redundancy to the axillary tunnel to avoid avulsion with extreme
arm abduction.Anticoagulate with heparin to achieve an ACT >250. Anarteriotomy is madeon the anterior inferior surface of the axillary artery, and an end-to-side
anastomosis is sewn using 5-0 prolene. The bevel can be made in the traditional
30-degree angle or in cobrahead fashion. Prior to completion of the anastomosis, the
artery is forward and back bled. Next create an arteriotomy on the common femoral
artery which should beextended onto the profunda or supercial femoral artery. An
end-to-side anastomosis is then sewn using 5-0 prolene. Prior to completion of the
anastomosis, the artery is forward and back bled as well as the graft.See Chap. 29
for more information regarding femoral-femoralbypass.
ab
30 Axillo-Femoral Bypass
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309
Diagrams oftheProcedure
Image showing “Proximal anastomosis of axillo-femoral bypass with two types of
conguration” Fig.30.1.
Figure 30.1a: 30° bevel
Figure 30.1b: Cobrahead bevel
Image showing “Course of tunnel for an axillobifemoral bypass,” (see Fig.30.2a).
Image showing “Details of femoral anastomosis,” (see Fig.30.2b).
Ax. art.
Ax. vein
30˚ bevel Cobrahead bevel
Fig. 30.1 Proximal anastomosis of axillo-femoral bypassgraft– two types of congurations
Pect.
minor
310
a
Fig. 30.2 (a) Course of
tunnel for axillobefemoral
graft. (b) Details of
femoral anastomosis
A. Lee
b
Pearls andComplications
30 Axillo-Femoral Bypass
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311
1. To avoid avulsion or excessive tension with extreme arm abduction, be sure to
leave a small amount of redundancy inthe graft.
2. Either axillary artery can be used if there is no disease in the subclavian/axillary
artery, but the right side is preferredif a left ank incision will be utilizedin a
future procedure.
3. If both axillary arteries are equal, inow is usually the same side as the worst leg.
4. If there is a systolic pressure difference in the arms that is greater than 10mmHg,
choose the arm with the higher pressure.
5. The axillary artery is fragile– avoid excess tension when sewing the anastomosis.
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