What are the steps for a Superficial Femoral Artery (SFA) to below-knee popliteal artery bypass?

From the Guidelines

The most effective approach for an SFA to below-knee popliteal bypass is to use autologous great saphenous vein as the conduit, as it provides the best outcomes in terms of patency and limb salvage, as recommended by the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline 1. The procedure begins with patient positioning in supine with the affected leg externally rotated and slightly flexed. After appropriate anesthesia (typically general or regional), the surgeon makes incisions at the groin to access the SFA and at the medial aspect of the leg below the knee to expose the popliteal artery. Systemic heparinization (typically 5,000-10,000 units IV) is administered before vessel clamping. The surgeon then creates a subcutaneous or anatomic tunnel between the two incisions for graft placement. Key considerations for the procedure include:

• The use of autologous great saphenous vein as the preferred conduit, as supported by the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines 1
• The creation of a subcutaneous or anatomic tunnel for graft placement
• The performance of proximal and distal anastomoses using 5-0 or 6-0 polypropylene suture in a continuous fashion
• The removal of clamps sequentially (distal first, then proximal) to restore flow, checking for hemostasis
• The use of layered wound closure with absorbable sutures for deep tissues and staples or nylon for skin Postoperatively, patients typically receive antiplatelet therapy (aspirin 81-325mg daily) and may require temporary anticoagulation, as noted in the European Society of Cardiology guidelines 1. This bypass provides a durable solution for limb salvage by creating an alternative pathway for blood flow around the occluded arterial segment. It is essential to follow the most recent guidelines, such as the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline, to ensure the best possible outcomes for patients undergoing this procedure 1.

From the Research

Steps for an SFA to Below Knee Popliteal Bypass

The steps for an SFA to below knee popliteal bypass involve several key considerations, including:

• Patient selection: Patients with critical limb ischemia (CLI) secondary to superficial femoral artery (SFA) occlusions and jeopardized tibial-peroneal run-off are potential candidates for this procedure 2.
• Access technique: The antegrade popliteal arterial access technique can be used to treat patients with SFA occlusions 2, while the retrograde popliteal access technique has also been shown to be effective and safe 3.
• Endovascular therapy: Combined superficial femoral artery endovascular therapy with popliteal-to-distal bypass may be a promising approach for patients with chronic limb-threatening ischemia 4.
• Bypass grafting: Distal origin grafts originating from the SFA or popliteal artery can be used to optimize inflow for distal origin bypass grafts 5.
• Imaging and follow-up: Standards for the use of basic and more advanced endovascular techniques in the femoropopliteal arteries, as well as relevant aspects of case selection, imaging, and follow-up, are reported in the literature 6.

Key Considerations

Some key considerations for an SFA to below knee popliteal bypass include:

• The use of drug-eluting stents (DES) or other endovascular devices to treat SFA lesions 2, 4.
• The importance of optimizing inflow for distal origin bypass grafts 5.
• The need for careful patient selection and case planning 2, 4, 3.
• The use of imaging and follow-up to monitor patient outcomes and graft patency 6.

Potential Outcomes

The potential outcomes of an SFA to below knee popliteal bypass include:

• Improved limb salvage rates 4, 5.
• Increased patency rates for distal origin bypass grafts 4, 5.
• Reduced risk of amputation and mortality 2, 4.
• Improved wound healing and overall patient outcomes 4.