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344
Ext. Hall. Long.
Post. Tib. Art.
S. S. Hans
Anastomosis toPeroneal Artery
Proximal and middle third of the peroneal artery can be exposed like exposure of
posterior tibial artery with takedown of soleus muscle from the soleal line and
unroong the fascia covering the exor hallucis longus muscle (Fig. 33.13).
Peroneal artery is the deepest artery and runs along the medial border of the bula.
Its exposure can be difcult in patients with “heavy” legs. The peroneal artery in the
distal one-third can also be performed via medial incision 1.5–2cm posterior to the
medial border of the tibia and dissection carried out similarly to the exposure of the
posterior tibial artery between exor hallucis longus and tibialis posterior anteromedially (Fig.33.14).
In some circumstances, particularly in patients with obesity, lateral approach following resection of the distal bula with a podiatric oscillating saw following a skin
incision about 8–10cm long on the skin covering the bula at this lower end can be
made (Fig.33.15). As the bula is divided, the neurovascular bundle underneath
should be carefully protected with periosteal elevators, and periosteum should be
carefully separated from the bone circumferentially to prevent damage to the neurovascular bundle (Figs.33.16 and 33.17). More commonly, the medial approach to
the peroneal artery is preferable in its distal one-third segment.
Tib. Ant.
Ext. Dig. Long.
Per. Long.
Per. Brev.
Fibula
Soleus
Plantaris
Lat. head.
gastroc
L.S.V.
Fig. 33.13 Transverse section of upper right leg for exposure of proximal peroneal artery
Tibia
Tib. post.
Popliteus
Peron. Art.
G.S.V
Med. head
gastroc
Soleus
Ti
.
33 Femoral-Infrapopliteal (Crural andParamalleolar) Bypass Graft
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Fig. 33.14 Transverse
section of lower left leg for
exposure of distal peroneal
artery
345
Fig. 33.15 Skin incision
of exposure of distal
peroneal artery via lateral
approach
Fig. 33.16 Exposed bula
b. post.
Flex. dig.
long.
Peron. art.
Flex. hall. long
Soleus
PER. long.
Soleus
346
Fig. 33.17 Partial
bulectomy
S. S. Hans
Complications
Postoperative complications following 1400 infra-inguinal grafts for chronic limb
ischemia reported by Kalish etal. included wound complications of 4%, graft occlusion 5.2%, major amputations 1.8%, and mortality of 2.7% [4]. Early thrombosis
(less than 30days) is most commonly the result of inadequate conduit (vein) kinking or twisting of the graft, poor outow. Patient should be taken back to the operating room for thrombectomy and arteriography. Late complications include persistent
lymphedema, aneurysmal changes vein bypass conduits, graft stenosis, and
infection.
References
1. Davis FM, Henke PK.Infrainguinal bypass graft for lower extremity arterial occlusive disease.
In: Hans SS, Shepard AD, Weaver MR, etal., editors. Endovascular and open vascular recon-
struction. Boca Raton, FL: CRC Press; 2018. p.319–27.
2. Ciervo A, Dardik H, Qin F, etal. The tourniquet revisited as an attempt to lower limb revascu-
larization. J Vasc Surg. 2000;31(3):436–42.
3. Wagner WH, Treiman DV, Cossman JL, etal. Tourniquet occlusion for tibial artery reconstruc-
tion. J Vasc Surg. 1993;18:637–47.
4. Kalish JA, Farber A, Homa K, et al. Factors associated with surgical site infection after
lower extremity bypass in the society for vascular surgery, quality initiative. J Vasc Surg.
2014;16(5):1238–46.
Chapter 34
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Upper Extremity Artery Bypass
FarahHanifAliMohammad
Surgical Anatomy
Axillary Artery
The axillary artery has three parts based on pectoralis minor. The rst part is superior and medial to the pectoralis minor and begins as continuation of the subclavian
artery at the lateral edge of the rst rib. Here it gives off its rst branch named the
superior thoracic artery. The second portion lies underneath the pectoralis minor
and gives off thoracoacromial and lateral thoracic artery. Third portion lies lateral to
the pectoralis minor and gives off subscapular, anterior, and posterior humeral circumex artery. It continues on to become brachial artery at the lower margin of teres
major. The axillary vein runs along its entire course medially. The brachial plexus
runs posterior to the rst and then interlaces the second and third part (Fig.34.1).
Brachial Artery
The axillary artery continues on to become the brachial artery past the inferior border of teres major. The brachial artery passes between the biceps and triceps muscles. In the antecubital fossa, it divides into the radial, interosseous, and ulnar
F. H. A. Mohammad (*)
Henry Ford Hospital, Detroit, MI, USA
© 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_34
347
348
Coracoid process
Fig. 34.1 Exposure of
axillary artery
F. H. A. Mohammad
Ax. vein
Ax. artery
Median nerve
Pect. minor
arteries to supply the soft tissues of the forearm. The median nerve runs along the
artery crossing from relatively lateral to medial position as it goes distally. Its rst
major branch called the deep brachial artery runs posteriorly and serves as a major
collateral in the setting of brachial injury. Two brachial veins closely run along the
artery in the brachial sheath. The brachial artery divides into radial and ulnar arteries at the level of the radial tuberosity (Fig.34.2).
Radial Artery
Radial artery arises in the antecubital fossa and runs distally along the anterolateral
border of the forearm underneath the brachioradialis muscle. It continues on to pass
through the anatomical snuff box and becomes part of the deep palmar arch. Along
its course, it’s accompanied by paired radial veins and gives off multiple collateral
branches (Fig.34.2).
Ulnar Artery
After its origin at the level just below the antecubital fossa, it passes obliquely distally, underneath the supercial exor muscles along the anteromedial portion of the
forearm. It passes over the ulnar border of the wrist over the pisiform bone, terminating in the supercial palmar arch (Fig.34.2).
ysm
34 Upper Extremity Artery Bypass
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Fig. 34.2 Exposure of
brachial, radial and ulnar
artery (Left)
349
Brachial art. aneur
Biceps
Ulnar nerve
Median nerve
Radial nerve
Brachioradialis
Flexor pollicis long.
Flexor carpi ulnaris
Flexor dig. profundus
Radial art.
Ulnar art.
Surgical Exposure
Once the extent of disease has been determined, the bypass can be planned accordingly. The proximal and distal vessel is exposed, and chosen conduit is tunneled.
Axillary Artery
The patient is positioned supine with the ipsilateral arm abducted to 90°. The rst
and second portions of the axillary artery are best exposed with an infraclavicular
incision approximately 2 cm below the clavicle. The incision is made from
350
mid- clavicle to anterior surface of deltoid, approximately 7–8 cm in length. If
more lateral or if the third portion needs exposure, the incision would have to be
extended on to the deltopectoral groove. (Details in Chap. 31).
F. H. A. Mohammad
Brachial Artery
The patient is placed supine with the arm abducted to 90° over an arm board. Entire
arm from the axilla to the hand are prepped and draped. To expose the brachial
artery in the arm, an axial incision is made on the medial aspect of the arm between
the biceps and triceps muscles. At the antecubital fossa, usually a transverse incision just inferior to the antecubital crease may be sufcient. However, if the aneurysm is large or more extensive exposure is needed, then an S-shaped incision is
more suitable. (Details in Chap. 31).
Radial Artery
Proximal radial artery can be exposed in via a transverse incision in inferior to the
antecubital fossa. In the forearm depending on the level, the radial artery is exposed
via a longitudinal incision over the volar forearm (Fig.34.1). Landmarks include
midpoint of antecubital crease to styloid process of radius. After ligating supercial
veins, the antebrachial fascia is incised along the medial border of the brachioradialis muscle. Distally, it lies between tendons of brachioradialis and exor carpi radialis muscles. At this aspect, the supercial radial nerve runs along its lateral aspect
and should be preserved during dissection. The accompanying paired veins should
be carefully mobilized off the artery.
Ulnar Artery
Proximal ulnar artery can be exposed in via a transverse incision in inferior to the
antecubital fossa. It then dives deep underneath the supercial exor muscle group.
In the forearm, it can be exposed via a longitudinal incision along the medial border extending from the medial condyle of the humerus to the pisiform (Fig.34.1).
After incising the antebrachial fascia, the ulnar artery can be isolated by laterally
retracting the exor digitorum supercialis muscle in the proximal forearm. As it
progresses distally, the best way to expose would be to medially retract the exor
carpi ulnaris. The ulnar nerve runs medially along the artery in the mid- to distal
forearm.
34 Upper Extremity Artery Bypass
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351
Bypass andConduit
Autogenous vein grafts are conduits of choice. Lower extremity veins especially
great saphenous veins are preferred. Cephalic vein can be used however is usually
very thin walled and may not be a good size match. Ultrasound should be used to
map the desired length of the vein. Prosthetic reconstruction may be utilized if there
are no adequate vein conduits for axillary and brachial bypasses.
Once the vein is harvested, based on size match, it may be used in a reverse or
non-reversed fashion. If non-reversed orientation is chosen, then the vein should be
distended with heparinized saline. Mills or Lemaitre valvulotome can be used to
perform valvulolysis. For axillary artery bypasses, the conduit can be tunneled anatomically. For more distal bypasses, a subcutaneous tunnel is usually created.
Complications
Nerve Injury: Understanding the relation to the artery to the surrounding structures
is key to avoiding technical complications. Injury to the brachial plexus during
proximal axillary dissection can lead to signicant morbidity. Median and ulnar
nerve injury can lead to hand numbness and tingling. Radial nerve injuries can lead
to radial nerve palsy, which can cause pain and a loss of function in the wrist, hands,
and ngers.
Chapter 35
Arterial Reconstructions inPatients
withHostile Groin
SachinderSinghHans
Surgical Anatomy
The common femoral artery is a continuation of the external iliac artery as the latter
ends at the inguinal ligament midway between the anterior superior iliac spine and
symphysis pubis. The common femoral artery bifurcates into the profunda femoral
artery which supplies blood ow to the thigh and the supercial femoral artery. The
supercial femoral artery runs longitudinally and at the middle and distal third of
the thigh as it passes through an opening in the adductor magnus tendon to become
the popliteal artery.
Common Femoral Artery
The common femoral artery (CFA) is the continuation of the external iliac artery as
it crosses under the inguinal ligament. Coursing in the femoral triangle and not
passing through the femoral triangle whose borders include the inguinal ligament
superiorly, the medial border of the sartorius muscle laterally, and the medial border
of the adductor longus muscle medially. Here it is surrounded by the femoral sheath
S. S. Hans (*)
Vascular and Endovascular Services, Henry Ford Macomb Hospital,
Clinton Twp, MI, USA
© 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_35
353
354
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with the femoral vein running just medial to the artery. Common femoral artery
gives off small branches which may include supercial epigastric artery, supercial
circumex iliac artery, and supercial and deep external pudendal artery. The artery
ends when it gives off its largest branch the profunda or deep femoral artery which
arises approximately 3.5cm below the inguinal ligament. The deep femoral artery
runs posteriorly and continues downward between the pectineus and adductor longus muscle. After the profunda femoral artery branch point, the common femoral
artery continues distally in the extremity as the supercial femoral artery. The
supercial femoral artery extends beneath the sartorius muscle in the thigh eventually passing through the adductor canal and continues as the popliteal artery.
S. S. Hans
Deep Femoral Artery
Deep femoral artery near its origin is crossed anteriorly by lateral circumex femoral vein, and it gives three branches:
1. Lateral circumex femoral artery which divides into ascending branch, trans-
verse branch, and descending branch.
2. Medial circumex femoral-transverse and ascending branch.
3. Perforating arteries.
Adductor Canal (Hunter or Subsartorial Canal)
Adductor canal is a tunnel in the middle third of the thigh in which femoral vessels
and saphenous nerve are enclosed. Femoral vessels continue from the subsartorial
canal into the popliteal fossa. The sartorius muscle lies anteriorly in the subsartorial canal.
Anatomic Variations
Common and supercial femoral artery (SFA) may be absent and replaced by the
inferior gluteal artery which accompanies sciatic nerve into the popliteal fossa. The
deep femoral artery may arise from the medial or posterior aspect of CFA.The origin of deep femoral artery is usually 2.5–5cm below the inguinal ligament.
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