Thoracofemoral Bypass: A Retroperitoneal Approach

1. Introduction

2. Surgical Approach

3. Bilateral Groin Incisions and Femoral Exposure

4. Thoracoretroperitoneal Incision and Access to the Retroperitoneum

5. Retroperitoneal Dissection and Exposure of the Aorta

1. Ultrasound Evaluation of the Aorta and Branches Before Clamping

6. Retroperitoneal Tunnels Over the External Iliacs and Under the Ureters

1. Administration of Mannitol
2. Heparinization

7. Proximal Anastomosis of Graft to Aorta

1. Prepare for Anastomosis
2. Occlusion with Side-Biting Clamp
3. Aortic Arteriotomy
4. Aortic Punch
5. Suture Anastomosis
6. Repair Microtearing with Pledgeted Sutures
7. Test Anastomosis
8. Duplex Ultrasonography to Interrogate Anastomosis and Aorta
9. Doppler to Interrogate Blood Flow to Viscera
10. Flush Graft

8. Right Distal Anastomosis of Graft to Femoral Artery

1. Advance Graft Through Tunnels to Femoral Arteries
2. Arteriotomy
3. Endarterectomy
4. Suture Anastomosis
5. Reperfuse Right Leg and Test Anastomosis

9. Left Distal Anastomosis of Graft to Femoral Artery

1. Reperfuse Left Leg, Test Anastomosis, and Confirm Distal Perfusion

10. Final Inspection and Hemostasis

1. Reversal of Heparin
2. Chest Tube

11. Closure

1. Diaphragm
2. Reapproximation of the Ribs
3. Abdominal Wall
4. Skin and Soft Tissues in Layers

12. Post-op Remarks