The shelving edge of the inguinal ligament may have to be partially divided if the aneurysm is large with inadequateexposure. A silastic loop doubled on itself is passed around the distal external iliac artery. Deep epigastric artery and deep cir­cumex iliac artery are exposed and preserved. Attention is then paid to the proxi­mal SFA and a silastic loop doubled on itself is passed as well. Dissection of the DFA may be technically difcult. Dissection is kept close to the lateral wall of the aneurysm. A branch of the profunda femoral vein is seen crossing the origin of the

DFA and should be carefully ligated and divided (Fig.12.3). Failure to expose this vein and ligate it may result in troublesome bleeding in this area. If the origin of the DFA is difcult to expose, then the intraluminal control can be obtained after open­ing of the aneurysm following the application of proximal and distal vascular clamps and passage of a Garrett dilator (no. 5 or 6 Teleex Inc.) into the mouth of the DFA.

Femoral anastomotic aneurysms most commonly occur at the site of femoral anas­tomosis of aortofemoral bypass graft. Femoral anastomotic aneurysm is most often caused by degeneration in the wall of the femoral artery. Anastomotic aneurysms typically present 5 years or later following aortofemoral bypass graft. Aneurysms greater than 2.5cm in diameter should be repaired. Symptomatic aneurysm with local compression symptoms also should undergo operative repair. Leaking femoral anastomotic aneurysm should be repaired on an emergent basis. Patients with sus­pected anastomotic aneurysms should undergo femoral duplex imaging followed by CT angiography of the entire graft to evaluate the remote possibility of infection (gas bubbles or uid) around the graft.

The previously placed groin incision for aortofemoral grafting is extended proxi­mally and distally depending upon the relationship of the aneurysm to the SFA and DFA. The dense scar tissue around the aneurysm necessitates a sharp dissection with a 15-blade scalpel cutting at an angle. It is important to stay on the outer wall of the aneurysm. The graft is exposed under the inguinal ligament in a similar man­ner as described in the femoral aneurysm repair. The graft is usually well incorpo­rated and is surrounded by sheath (Fig.12.7). The common femoral artery posterior to the prosthetic graft is most often occluded. In most patients, the CFA proximal to artery anastomosis is usually sacriced as the anastomosis at this site following removal of the femoral anastomotic aneurysm is not recommended. Mobilization of the DFA in the proximal SFA is like as described in femoral artery repair chapter. Systemic heparin (100units/kg) is administered by the anesthesia team. Aneurysm is opened following proximal clamping and placing vascular clamps on the SFA and DFA. As the aneurysm is opened, the sutured line of the anastomotic aneurysm from the previously placed femoral anastomosis of the aortofemoral graft is exposed and the graft is then circumferentially removed from the host artery (CFA and proxi­mal SFA).

After removal of the aneurysm, a proximal anastomosis is performed end to end to the femoral limb of the aortofemoral graft and distal anastomosis is performed end to end within an oblique orientation incorporating the proximal SFA and DFA.In some patients, distal anastomosis is performed end to end to the proximal SFA and DFA, which will need to be reimplanted into the interposed Dacron graft with a continuous suture of 4-0 or 5-0 cardiovascular polypropylene (Fig.12.8).