Is a femoral‑popliteal bypass placed distal to the inguinal ligament (below the inguinal region)?

Femoral-Popliteal Bypass Anatomical Location

Yes, a femoral-popliteal (fem-pop) bypass is placed entirely below the inguinal ligament, as it is classified as an infrainguinal outflow procedure that originates from the femoral artery (which lies distal to the inguinal ligament) and extends to the popliteal artery. 1

Anatomical Classification

Infrainguinal Disease Category:

• Femoral-popliteal bypasses are explicitly categorized as "outflow procedures for infrainguinal disease" by ACC/AHA guidelines, distinguishing them from inflow procedures that address aortoiliac disease above the inguinal ligament. 1

Vessel Location:

• The common femoral artery, which serves as the typical origin point for fem-pop bypasses, is located immediately distal to (below) the inguinal ligament. 1, 2
• The superficial femoral artery continues distally from the common femoral artery and becomes the popliteal artery as it passes through the adductor canal. 2

Bypass Configuration Options

Above-Knee Popliteal Anastomosis:

• When the distal anastomosis is placed to the above-knee popliteal artery, autogenous saphenous vein should be used when possible (Class I, Level of Evidence A). 1
• Prosthetic material (PTFE or Dacron) can be used for above-knee bypasses with acceptable patency rates (5-year patency approximately 47-68% for prosthetics versus 69-81% for vein). 1, 3

Below-Knee Popliteal Anastomosis:

• Bypasses to the below-knee popliteal artery should be constructed with autogenous vein when possible (Class I, Level of Evidence A). 1
• Prosthetic material can be used effectively for below-knee popliteal bypasses only when no autogenous vein is available from any source (Class IIa, Level of Evidence B). 1

Origin Point Selection

Most Distal Suitable Artery:

• The most distal artery with continuous flow from above and without stenosis greater than 20% should be used as the point of origin for distal bypass (Class I, Level of Evidence B). 1
• The superficial femoral or popliteal arteries can serve as inflow sources if minimally diseased, potentially offering superior patency rates (81% versus 66% at 6 years for popliteal bypasses). 4

Common Pitfall to Avoid

Do not confuse infrainguinal (below inguinal ligament) procedures with infrapopliteal (below knee) procedures—femoral-popliteal bypasses are infrainguinal but may be either above-knee or below-knee depending on the distal anastomosis site. 1