What is the recommended peri‑operative and postoperative management of an adult undergoing femoral‑to‑femoral or femoral‑popliteal bypass for peripheral arterial disease?

Management of Femoral Bypass Graft

Conduit Selection

For femoral-popliteal bypass, autogenous vein is the mandatory first choice over any prosthetic material, as it provides superior long-term patency and reduced need for reintervention. 1

• Autogenous vein (saphenous) achieves 70% patency at 5 years and should be used whenever available, whether in situ or reversed configuration 1
• Prosthetic grafts (PTFE or Dacron) to the popliteal artery demonstrate significantly reduced patency rates and increased rates of repeat intervention compared to vein 1
• Above-knee prosthetic bypass shows 64-68% patency at 5 years, which is acceptable only when autogenous vein is unavailable 2
• Below-knee prosthetic grafts should be avoided entirely due to accelerated failure rates, particularly with poor tibial runoff 1

Perioperative Management

Preoperative Assessment

• Cardiac evaluation is critical, as myocardial infarction accounts for 0.8-5.2% of perioperative complications and represents the leading cause of operative mortality 3, 4
• Assess renal function preoperatively, as renal failure occurs in 0-4.6% of cases and contributes significantly to morbidity 3
• Evaluate bilateral lower extremity arterial anatomy to determine if combined inflow and outflow disease exists 1, 5

Anesthesia

• General or regional anesthesia may be used for femoral-popliteal bypass procedures 1

Surgical Technique Considerations

Addressing Combined Disease

When both inflow (iliac) and outflow (femoral-popliteal) disease coexist in critical limb ischemia, address inflow lesions first. 3, 5

• If CLI symptoms or infection persist after inflow revascularization, perform the outflow (femoral-popliteal) bypass as a second procedure 3, 5
• Hybrid revascularization combining common femoral endarterectomy with iliac stenting should be performed as a one-step procedure when feasible 5

Anastomotic Site Selection

• Above-knee popliteal anastomosis is preferred when the popliteal artery is patent, as it provides similar patency to below-knee vein grafts while allowing prosthetic use if vein is unavailable 2
• The site of popliteal anastomosis (above versus below knee) is a major determinant of outcomes, with above-knee locations generally favored for prosthetic conduits 1

Postoperative Management

Early Complications to Monitor

Graft infection occurs in 2.6% of femoral-popliteal bypasses and carries devastating consequences, with 26.5% ultimately requiring major amputation. 6

• Postoperative hematoma increases graft infection risk 3.4-fold and requires aggressive prevention and early drainage if it occurs 6
• Monitor for superficial wound infection (19-38% incidence), which can progress to graft infection 6
• Staphylococcus aureus is the most common pathogen (56%) in bypass graft infections 6
• 30-day readmission occurs in 21-47% of patients and is independently associated with subsequent graft infection 6

Surveillance Protocol

• Lifetime surveillance is mandatory for all aortofemoral and femoral-popliteal bypass patients due to ongoing risk of graft-related complications 4
• Monitor for graft thrombosis, which occurs at a mean of 24.8 months postoperatively in 7.9% of limbs 4
• Assess for pseudoaneurysm formation, which develops in 3.8% of limbs at a mean of 57.8 months 4

Expected Outcomes

Patency Rates

• Autogenous vein femoral-popliteal bypass: 70% primary patency at 5 years 2
• Prosthetic above-knee bypass: 64-68% primary patency at 5 years 2
• Aortobifemoral bypass: 88% primary patency and 93% secondary patency at 5 years 4

Mortality and Morbidity

• Perioperative mortality for femoral-popliteal bypass is 0-6%, substantially lower than major amputation (4-30%) 3
• Aortobifemoral bypass carries 4.9% perioperative mortality, with over half of deaths from myocardial infarction 4
• Limb salvage rate is 95% at 5 years and 91% at 10 years for aortobifemoral bypass 4

High-Risk Patient Alternatives

For patients with extensive aortoiliac disease who cannot tolerate aortobifemoral bypass, axillofemoral-femoral bypass is indicated despite lower patency rates. 3, 5

• Axillofemoral-femoral bypass has 4.9-6% operative mortality, making it suitable for high-risk patients 3, 5
• Sequential axillofemoral-popliteal grafts achieve 74% 3-year patency, superior to straight axillopopliteal grafts (42%) 7

Critical Caveats

• Prosthetic grafts increase graft infection risk 3.7-fold compared to autogenous vein 6
• Femoral-tibial bypass with prosthetic material should never be performed for claudication due to unacceptably poor outcomes 1
• Revascularization should not be performed solely to prevent progression from claudication to CLI, as procedural risks outweigh hypothetical benefits 1