# Bilateral groin exploration, Thrombectomy of Fem-fem Bypass



## hcg (Aug 9, 2013)

Can anyone please help me with this procedure? I'd sure do appreciate all the help I can get. Thank you.


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PREOPERATIVE DIAGNOSIS: Progressive lifestyle disabling claudication of the left leg.
POSTOPERATIVE DIAGNOSIS: Anastomotic stricture of proximal and femoral-femoral bypass.
SURGEON: Dr. A
ASSISTANT: Dr. B
ANESTHESIOLOGIST:
ANESTHESIA: General
OPERATION: Bilateral groin exploration, thrombectomy of fem-fem bypass. Intraoperative arteriogram. Take-down and revision of proximal anastomosis of femoral-femoral bypass.

ESTIMATED BLOOD LOSS
500.

INDICATIONS
This patient is admitted with peripheral vascular disease and a known left iliac occlusion. Patient had previous femoral-femoral bypass that failed. Has had progressive lifestyle disabling claudication and requested surgical revision. I offered exploration of the groin, and possible thrombectomy and possible revision, possible re-do femoral-femoral bypass. The risks including bleeding, infection, injury to the vessels of the groin, as well as risks of anesthesia, were discussed. Potential risk for exacerbation of the patient's known vascular disease or deterioration were discussed at length and the patient's questions were answered.

DESCRIPTION OF PROCEDURE
The patient was identified, received intravenous antibiotics preoperatively and was brought to the operating room and placed in supine position. General endotracheal anesthesia was administered. Foley catheter was inserted. The abdomen, groins and thighs were prepped with ChloraPrep and appropriately draped with an Ioban drape.

I began the operation by reopening of the right groin incision. A vertical incision was reopened. Subcutaneous dissection was performed. The fem-fem bypass graft was identified and subcutaneous tissues and was controlled with a vessel loop.

The graftotomy was created transversely. Through this graftotomy, a #4 Fogarty embolectomy catheter was passed distally to the left leg over the pelvis and the thrombectomy was performed of some old clotted material.

Arteriography was then performed using full strength Conray and fluoroscopy. Initial images were difficult to interpret. There might have been some mild narrowing at the anastomosis, but ultimately this improved. There was a little bit of spasm in the SFA to begin with but this also ultimately cleared. It was my opinion after further evaluation, that there was only minimal stenosis of the distal anastomosis. I felt that this was,  therefore, not the explanation for the patient's thrombosed graft.

Efforts were then made to do a thrombectomy of the proximal anastomosis but this met with significant difficulty. I could not pass the embolectomy catheter. I was able to pass with some difficulties the coronary dilators. Angiography was also difficult and appeared to be there was an obstruction of the proximal anastomosis. I therefore, chose to revise this. Before doing so, however, and because I was initially concerned about the arteriogram on the left anastomosis, I did open the left groin, explored this area and did a thrombectomy through the left groin, through the distal most end of the femoral-femoral bypass graft by making a graftotomy and passing a #4 Fogarty embolectomy catheter distally. I had good back bleeding and no thrombus.

This arteriotomy was closed using CV6 Gore-Tex suture.

As I turned my attention back to the right side and the proximal anastomosis, I used a Satinsky-type clamp to occlude the common femoral artery centered around the proximal anastomoses of the femorofemoral bypass. I then cut through the artery, which had previously been repaired with a patch angioplasty and in so doing, I was able to excise the femoral-femoral bypass proximal anastomosis. There was indeed accumulation of thrombus and scar in this area such that the proximal anastomosis was nearly completely occluded and this area was sent for pathologic evaluation.

I used a 10 cm interposition 6 mm diameter Propaten Gore-Tex graft. I sewed the proximal end down onto the common femoral artery after spatulating the graft. The graft was sewn onto the artery using CV6 Gore-Tex suture and this was performed circumferentially with a single suture. Once the proximal anastomosis was completed, flow was re-established through the femoral artery into the right leg. It should be noted that prior to occluding the femoral artery on the right side, I did instruct the anesthesia service to give the patient 4000 units of intravenous heparin.

Lastly, the interposition graft was sewn to the previously placed femoral-femoral bypass graft in an end-to-end fashion also using a CV 6 Gore-Tex suture. The anastomosis was completed, flow was re-established to the graft and there was good Doppler flow. Examination of the feet confirmed excellent flow with improved signals in the left foot compared to preop.

Both wounds were irrigated with saline until the effluent was clear. Nu-Knit was used to achieve hemostasis of the anastomoses. Both wounds were closed in a similar fashion using running 3-0 Vicryl in several layers reapproximate the subcutaneous tissues. Skin was then closed with 4-0 Monocryl in a fashion. Steri-Strips and dry dressings were applied. The patient tolerated the procedure well and without obvious complication.


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