FemoroFemoral Bypass 

Background

Femorofemoral (femoral-femoral) bypass is a method of surgical revascularization used in the setting of unilateral common and/or external iliac artery occlusive disease. The technique is dependent upon a patent iliac arterial system without hemodynamically significant disease to supply adequate inflow of blood to both lower extremities. It is a commonly used means of extra-anatomic vascular reconstruction for patients with disabling claudication or critical limb-threatening ischemia (CLTI) in whom underlying anatomic constraints rule out endovascular means of restoring in-line flow and those who do not qualify for anatomic reconstruction because of comorbidities that preclude a more invasive open approach.

Femorofemoral bypass may also be used as a component of endovascular repair of abdominal aortic aneurysms (AAAs),  whereupon one aortoiliac system is occluded on an emergency or elective basis to ensure exclusion of the aortic aneurysm. Primary patency rates of femorofemoral bypasses are estimated to be in the range of 65-70% at 5 years.  The bypass patency rates, however, are inferior to in-line reconstruction benchmarks set by the aortofemoral and iliofemoral bypass operations.

Indications

Indications for femorofemoral bypass are as follows:

• Symptomatic lower-extremity ischemia (disabling claudication, rest pain, tissue loss) due to acute or chronic occlusion of a unilateral iliac artery system

• Adjunct to an endovascular unilateral aortoiliac exclusion of an AAA

• Unavailability of endovascular options for management of iliac occlusive disease

• High-risk patients with significant comorbidities (cardiopulmonary disease, multiple prior abdominal operations, prior radiation therapy to the abdomen, abdominal stoma) that preclude in-line reconstruction with inflow from the proximal iliac artery or the aorta.

Contraindications

Contraindications for femorofemoral bypass are as follows:

• Compromised inflow aortoiliac arterial segment

• Significant obesity that may cause unfavorable graft geometry

• Extreme medical risks for surgery

Preprocedural Evaluation

• Preoperative workup should begin with noninvasive arterial physiologic studies, including ankle-brachial index (ABI) and arterial wave form analysis by duplex ultrasonography (US). If iliac occlusive disease is suspected, at least one imaging study should be performed for assessment of the arterial anatomy. Computed tomography (CT) angiography (CTA), magnetic resonance angiography (MRA), or arteriography provides anatomic information for the needed revascularization procedure.

• If femorofemoral (femoral-femoral) bypass is indicated, a thorough imaging assessment of the inflow iliac system is critical in that it facilitates planning for possible adjunctive procedures (ie, endovascular interventions or limited endarterectomy) to ensure the success of the reconstruction and augment overall long-term graft patency. 

Equipment

Equipment employed for a femorofemoral bypass is as follows:

• Standard vascular clamps and instruments

• ·Tunneling device (ie, Gore tunneler; W. L. Gore and Associates, Flagstaff, AZ)

• Polytetrafluoroethylene (PTFE) or Dacron-based aortic grafts (8-10 mm) of appropriate length and configuration

• Continuous wave Doppler device to assess blood flow intraoperatively

Most femorofemoral bypasses are constructed with prosthetic grafts. Dacron or PTFE-based grafts are most commonly used for the procedure. Autogenous (vein) and biologic grafts (cadaveric vein or artery) may also be used if prosthetic reconstruction is contraindicated because of the presence of an active infection or contamination of the surgical field. Most studies have not shown differences in patency rates among the various types of graft used. A study by Nguyen et al found femoral vein grafts to have superior patency as compared with PTFE grafts. [10] Externally supported grafts may facilitate graft tunneling and lie. 

Patient Preparation

Anesthesia

Femorofemoral bypass is most often performed with general anesthesia because tunneling of the graft can be difficult to tolerate. In cases where underlying cardiopulmonary disease precludes general anesthesia, however, the procedure can be performed with regional (spinal) or local anesthesia and sedation.

Positioning

The procedure is performed with the patient positioned supine, and a wide sterile field is prepared from the abdomen to the lower anterior thighs.

SURGICAL INSTRUMENTS & O.R. NEEDS

INSTRUMENTS:

AV Graft Set

Light handle

Prep bowl

Prep set (Pick up cannister)

Tunneler with 4 heads

Dr. Kaw’s tunneler (optional/standby)

(1) Medium weitlaner

Elbow retractor (optional/standby)

Potts scissors

LCA Small

LCA Medium

Marylou

PVAS Curve

PVAS Straight

Derra

C- clamp

Castroviejo

EXTRA Gregory

EXTRA Gerald forceps

EXTRA Mosquito curve

OR NEEDS:

Disposable Laparotomy pack

Sterile Gloves

Lubricating jelly

Syringes (10 cc, 1cc)

Povidone Iodine 7.5%, 10%

Blade 15, 11

Sterile water for injection (50 cc)

Operating Sponge

Aseptosyringe

Cautery cord

Cautery pad(dual)

Suction tubing

Foley catheter (size depends on age)

Urine bag

Vessel loops (at least 6 pcs)

FUT

Shud

Ligaclips (Small/Medium)

Alcohol

0.9% Sodium chloride Irrigating

EXTRA Disposable gown

Spongostan/Gelfoam (optional/standby)

Tegaderm/Opsite (all sizes standby)

 SUTURES:

Prolene 5-0 RB2, 6-0 BV-1 or any equivalent

Vicryl 2-0, 3-0, 4-0 or any equivalent 

DRESSING:

OS with tegaderm

References

1. Akingboye AA, Patel B, Cross FW. Femorofemoral Crossover Bypass Graft Has Excellent Patency When Performed with EVAR for AAA with UIOD. South Med J. 2018 Jan. 111 (1):56-63. [QxMD MEDLINE Link].

2. Mingoli A, Sapienza P, Feldhaus RJ, Di Marzo L, Burchi C, Cavallaro A. Femorofemoral bypass grafts: Factors influencing long-term patency rate and outcome. Surgery. 2001 Apr. 129 (4):451-8. [QxMD MEDLINE Link].

3. Devolfe C, Adeleine P, Henrie M, Violet F, Descotes J. Ilio-femoral and femoro-femoral crossover grafting. Analysis of an 11-year experience. J Cardiovasc Surg (Torino). 1983 Nov-Dec. 24 (6):634-40. [QxMD MEDLINE Link].

4. Pai M, Handa A, Hands L, Collin J. Femoro-femoral arterial bypass is an effective and durable treatment for symptomatic unilateral iliac artery occlusion. Ann R Coll Surg Engl. 2003 Mar. 85 (2):88-90. [QxMD MEDLINE Link].

5. Ma T, Ma J. Femorofemoral bypass to the deep femoral artery for limb salvage after prior failed percutaneous endovascular intervention. Ann Vasc Surg. 2014 Aug. 28 (6):1463-8. [QxMD MEDLINE Link].

6. Jorshery SD, Luo J, Zhang Y, Sarac T, Ochoa Chaar CI. Hybrid surgery for bilateral lower extremity inflow revascularization. J Vasc Surg. 2019 Sep. 70 (3):768-775.e2. [QxMD MEDLINE Link].

7. Saadeddin ZM, Rybin DV, Doros G, Siracuse JJ, Farber A, Eslami MH. Comparison of Early and Late Post-operative Outcomes after Supra-inguinal Bypass for Aortoiliac Occlusive Disease. Eur J Vasc Endovasc Surg. 2019 Oct. 58 (4):529-537. [QxMD MEDLINE Link]. [Full Text].

8. Saadeddin ZM, Borrebach JD, Hodges JC, Avgerinos ED, Singh M, Siracuse JJ, et al. Novel bypass risk predictive tool is superior to the 5-Factor Modified Frailty Index in predicting postoperative outcomes. J Vasc Surg. 2020 Oct. 72 (4):1427-1435.e1. [QxMD MEDLINE Link].

9. Huded CP, Goodney PP, Powell RJ, Nolan BW, Rzucidlo EM, Simone ST, et al. The impact of adjunctive iliac stenting on femoral-femoral bypass in contemporary practice. J Vasc Surg. 2012 Mar. 55 (3):739-45; discussion 744-5. [QxMD MEDLINE Link]. [Full Text].

10. Nguyen KP, Moneta G, Landry G. Venous Conduits Have Superior Patency Compared with Prosthetic Grafts for Femorofemoral Bypass. Ann Vasc Surg. 2018 Oct. 52:126-137. [QxMD MEDLINE Link].

11. Kim YW, Lee JH, Kim HG, Huh S. Factors affecting the long-term patency of crossover femorofemoral bypass graft. Eur J Vasc Endovasc Surg. 2005 Oct. 30 (4):376-80. [QxMD MEDLINE Link].

12. Stone PA, Armstrong PA, Bandyk DF, Keeling WB, Flaherty SK, Shames ML, et al. Duplex ultrasound criteria for femorofemoral bypass revision. J Vasc Surg. 2006 Sep. 44 (3):496-502. [QxMD MEDLINE Link].

13. [Guideline] Zierler RE, Jordan WD, Lal BK, Mussa F, Leers S, Fulton J, et al. The Society for Vascular Surgery practice guidelines on follow-up after vascular surgery arterial procedures. J Vasc Surg. 2018 Jul. 68 (1):256-284. [QxMD MEDLINE Link]. [Full Text].

14. Gouveia E Melo R, Martins B, Pedro DM, Santos CM, Duarte A, Fernandes E Fernandes R, et al. Microbial evolution of vascular graft infections in a tertiary hospital based on positive graft cultures. J Vasc Surg. 2021 Jul. 74 (1):276-284.e4. [QxMD MEDLINE Link].