Right femoropopliteal bypass with a PTFE graft (PIII)

The longitudinal skin incision is made distal to the inguinal region on the proximal thigh, approximately 1 cm lateral to the palpable femoral artery. After transecting the subcutaneous tissue, the femoral fascia is incised longitudinally medial to the sartorius muscle. At the caudal edge of the incision, the fascia of the adductor canal is opened, the superficial femoral artery is exposed and encircled with a vessel loop. The lymph collectors crossing beneath the inguinal ligament are divided between Overholt clamps and secured with transfixion ligatures. The lymph nodes are enlarged due to PAOD Fontaine grade IV.

Tips:

1. Access lateral to the femoral artery spares the lymph collectors and permits subsequent offset layered closure with the aim of reliable wound healing.

2. The superficial femoral artery serves as a landmark for proximad dissection lateral to it. This helps to easily locate the deep and common femoral arteries and also avoids the risk of injury to the veins running medially.

3. Transfixion ligation of the lymph collectors helps, to a large extent, to prevent subsequent lymphatic cysts and fistulae. In PAOD grade IV, postoperative lymph collection in the groin not infrequently paves the way for deep wound infection with fatal consequences for the limb and possibly even for the patient's life.

Dissect along the superficial femoral artery proximad to expose the common femoral artery, which is encircled with a vessel loop. Expose the deep femoral artery and the medial and lateral circumflex femoral arteries. Encircle the vessels and place a moist gauze pad.

Access to the first segment of the popliteal artery is achieved through a skin incision above the knee joint on the medial thigh (transition from the middle to the distal third of the thigh width). After transecting the subcutaneous tissue, incise the femoral fascia longitudinally anterior to the sartorius muscle and retract the muscle posteriorly. Insert a retractor (e.g. a van Dongen retractor). Locate the vascular bundle at the inferior margin of the adductor canal, incise the popliteal fat pad, and expose the popliteal artery in its first segment. Divide any crossing veins between ligatures during dissection. After encircling the popliteal artery, clamp it.

Contrary to the preoperative angiogram, the severely arteriosclerotically stenosed popliteal artery is thrombotically occluded in segments 1 to 2. The thrombus is already beginning to organise and adheres to the wall. Therefore, the attempted thrombectomy with the Fogarty catheter via the longitudinally incised popliteal artery is unsuccessful. The popliteal artery is ligated proximal and distal to the arteriotomy (not shown in the video).