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Femoral to Distal Bypass with Conduit (Cadaver)

Samuel Schwartz, MD; Adam Tanious, MD
Massachusetts General Hospital

Transcription

CHAPTER 1

Draw a line between, it's your inguinal ligament. Correct, all right, so, this is your inguinal ligament, ASAS to pubic tubercle, and essentially right- do a longitudinal incision that spans the mid-point of the 2, was one third above and two thirds below, okay?

Let's feel if we could feel any thrombosed femoral artery. Feels like there's something right in there, but I can't really delineate, really tell.

Inguinal ligament should be coming up soon. Isn't it right there? Yes, so, there's the inguinal ligament, which is our main landmark that we really identify first. Weitlaners. Thanks. And the vein right there. Yes, right angle. You want to throw some 3-0's? I would just take a big wad of it, so we could just... Tie it off? Yes, just tie off the entire thing, or I would go from like here to here, like a huge- move, you know? Let's take a 3-0 like that and then tie it off like that. Yes, that's fine. I was thinking something more like this, you know? Okay. All right, so now, let's just keep marching away. Sharply or bluntly? I think let's do sharp until we identify the artery. So, what I typ- what I typically do is delineate the lower border- caudal border of the, inguinal ligament, which is sort of adhesed a little bit here. I want to get into it though, you know? So this is more of it down here, and so, let's just pull that all up. Switch to the Debakey actually. Yes, so let's see, let's just come this way- until we really have that space. Okay, now let's just take a feel and see what we have. Let's take some of this open. I think we need to be a little bit more medial. Let's take a feel again. I think it's right here. Feel that tubular structure, right there? Oh, right here? Yes. So we've already ligated one side, so tie this side. So, really we're just essentially getting down to the main femoral artery. Now let's just take a feel, it's right here. Feel it. Feel that? Okay. So, I'm going to hold right here on this side, and just essentially cut right down to it. So here is a rock, she's got a huge plaque in her common femoral artery, which was nice, because that gives you the ability to sort of find it easier in a pulseless artery. Medial circumflex. Yes, I would say maybe even inferior epigastric, right? Yes, I guess we're- so now we need to come on this side of it. So I'm just going to take this and just sort of come through that. So pull up that side there for me. Thank you. I'm looking for a lateral- branch. Let's get a right angle. Typically we go around, so we don't injure the vein, but we're just going to take it now, this way- usually it's a medial to lateral. So now we have what looks like the distal common femoral isolated- I'll have you just put a finger on that for me. And now we have potentially a bifurcation here- to the superficial femoral artery and profunda. Okay, let's get a curved Metz, or a curved Mayos. 3-0 ties? So there's a bifurcation right there, right? Okay, right angle, got It. So this is more of a lateral circumflex femoral branch, which is seen off the common femoral rarely. Not commonly seen. I'll hold this if you want to essentially get the SFA and profunda, or at least SFA isolated. Yes, that should be- maybe that's maybe a branch right there, huh? Come below that area. You see that? It's got that tethered thing- appearance of a branch. Get a right angle? Yes. 3-0 ties again. Thank you. So there's a small side-branch coming off the SFA that we're just controlling right now. No, I think that's okay, just to do it like that, here you go. Okay, good. So she's got a low-hanging bifurcation. So one good way to essentially get profunda control is by taking your common femoral and your SFA, rotating them both medially, and then- take your Metz- and then just ise a little bit more of that profunda. Yes, that's probably the venous branch that crosses the profunda, so we don't need to take that. So hold these here for me and I'll take that right angle. So one way to do this is essentially to get it by exclusion. So you take a vessel loop around the common femoral. Bring it on the side of you. And then you take it around the SFA, and now you've got essentially profunda control. So that is essentially an exposure of a femoral complex. Now let's do the distal target. Okay.

CHAPTER 2

So, you essentially take the edge of the tibia, which is here, and you're about a fingerbreadth posterior to it. So, what- which is about here to here. That's the start of the incision, we may want to extend it.

And in this exposure, we're taking the gastroc muscle and reflecting it posteriorly. And then the sartorius- gracilis and semitendinosus are reflected anteriorly and can be actually divided. Also in this exposure, we could get to the- greater saphenous vein for a bypass, which we may encounter.

Keep going, just try to keep this out of the way. All right, so tie your side. So come through here, just sharply. The muscle in these is really adhesed, so stay a little bit- I'll cheat a little anteriorly. See if you can get a plane there. There's a little bit of a plane, see? So come this way with it, yes. Cheat a little anterior. Extend this a little bit. So, now take- keep taking this muscle, there you go. So we just want to reflect- this is the gastroc, and take it up a little bit higher here with the skin. So right here? Yes, that's fine. Is that a branch right there? 3-0 tie. So this looks like potentially the saphenous. Based on its vector, it's running sort of along the posterior aspect of the knee and more posteriorly. Yes, we'll grab this towards you, exactly. Just through here? Yes, that's fine. So we got to keep mobilizing this gastroc posteriorly. So stay on its border. Now I take a feel. Yes, so feel right where the femoral comp- or the popliteal artery is. You can feel that tubular compressed structure deep. It's not going to be easy to expose. That's a little popliteal potentially. Thank you. Sorry, I'm moving the table. Cut that there. Okay. I was thinking that that's the anterior tibial coming off of it, going that way, or...? Yes, I think so. Right there? Right there. So, this could be tibial-peroneal trunk, and then deep inside- if you point- that could be the anterior tibial, then the below-knee pop is essentially right above that. Okay?

CHAPTER 3

This is as anterior as you can. Happy right there? Yeah, that's fine. And we're just cutting through, and then? Yes, just the anterior wall, just to get intraluminal. Okay. Let's see- Metz. Okay. Hold your side open a little bit, I'm going to take this little bit of the wall off, just to make it a little bit bigger. Okay? And let me see- let go of your side if- and when you're grabbing, just do it like a full thickness since it's separating, you know? So that's pretty reasonable. Let's go a little bit higher. So this is an arteriotomy in the common femoral. Great. Let's get some stays.

So this is a 5-0 for a stay. Okay. Just to keep the flat of the wall? Yes, just to stay up, yes. Exactly, yes, exactly. We try to do it like at the 50% midpoint, you know, which is probably about where you were. I'll take a SNaP.

So at this point the patient would be fully heparinized with clamps on the common femoral, the superficial femoral artery, and the profunda artery. And then now we're essentially trimming the graft appropriately. Do you have 1 more SNaP? So now we- essentially just look at the- size of our graftotomy, and confirm that it's about the length of our arteriotomy, which I think it will be.

Okay. So to start the parachute, we essentially do 2- like a mattress in the back of the graft. Make them equivalent. Good. And then just hold that one up, and I'm going to start with this side. So, unlike the carotid, you want to take good, decent-depth bites- of the artery. So it's 3 on each side to do a true parachute, but you could go upwards of even 5. And this has got- since she's such a thin lady, this is a better exposure than the pop by far. I'll take a SNaP. Gotcha. Yes, a little bit more attention on those, yes. So it's typically out-to-in on the graft. And then in-to-out on whatever vessel you're sewing the graft to- vein or artery. Okay, so, hold that, and then I'll hold this side here, and then we essentially just go back and forth until this comes down. Pull yours up a little bit. So, I'll just do a few on my side forehand, and then you could take over on your side and do forehand. Okay. We need to make more travel on the artery side. So if you don't mind grabbing a scissors and just cutting out the stay. So now we essentially just go beyond the 50% mark. Whatever Proline you gave me, is this 5-0? I mean, it's great. We'll take- well, if you have another one open. Yes. Oh, perfect. Okay if I take it in 1, or? Yes, you can. There you go, needles to you. Yes, maybe do 1 more. And I like that you're diagonal with your travel because we need more artery makeup than anything. And this is getting SNaPed? Uh-huh. So, yes, just take it on both sides of this and just fire it through. Oh, you want to U it, or do you... Yes, just a U-stitch. I'm just going to do it in 2. Yes, that's a good call. Vicryl, just to close. Vicryl? Yes. Vicryl, like 2-0 or 3-0, whatever you have, and then just- you could do a subcuticular as well. Okay. So now what we're doing is we're anchoring what they call the toe of the graft. These last bits right here, we need to take good thick bites on the common femoral because this artery on that side's a little thinned out. So, there's no need to do a flushing maneuver with- you could complete the entire anastomosis- because you still have the distal graft open. So cut me right here. And then that back, yes. So, Boitano, we'll take some- like Vicryl. Thank you. So that's the proximal anastomosis essentially completed with a parachute-style.

CHAPTER 4

And we are going to actually to close this incision- given that the distal is a little deep and will be very difficult to visualize because everything looks the same.