Unusual surgical exposures to avoid scarred or infected standard access routes to the common femoral, deep femoral, and popliteal arteries Frank J. Veith,

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Presentation transcript:

Unusual surgical exposures to avoid scarred or infected standard access routes to the common femoral, deep femoral, and popliteal arteries Frank J. Veith, MD, Enrico Ascher, MD, Neal S. Cayne, MD Journal of Vascular Surgery Volume 64, Issue 4, Pages 1160-1168 (October 2016) DOI: 10.1016/j.jvs.2016.03.472 Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 1 Diagram of exposed external iliac vessels and deep plane medial to the sartorius muscle. (Reproduced with permission from Ascer E, Kirwin J, Mohan C, Gennaro M. The preferential use of the external iliac artery as an inflow source for redo femoropopliteal and infrapopliteal bypass. J Vasc Surg 1993;18:234-41.) Journal of Vascular Surgery 2016 64, 1160-1168DOI: (10.1016/j.jvs.2016.03.472) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 2 A connecting tunnel is created by blunt dissection along anterolateral border of external iliac and femoral arteries and deep to the inguinal ligament. (Reproduced with permission from Ascer E, Kirwin J, Mohan C, Gennaro M. The preferential use of the external iliac artery as an inflow source for redo femoropopliteal and infrapopliteal bypass. J Vasc Surg 1993;18:234-41.) Journal of Vascular Surgery 2016 64, 1160-1168DOI: (10.1016/j.jvs.2016.03.472) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 3 Diagram shows the proximal anastomosis between prosthetic graft and external iliac artery showing the position of the graft anterolateral to the arteries and deep to the inguinal ligament. (Reproduced with permission from Ascer E, Kirwin J, Mohan C, Gennaro M. The preferential use of the external iliac artery as an inflow source for redo femoropopliteal and infrapopliteal bypass. J Vasc Surg 1993;18:234-41.) Journal of Vascular Surgery 2016 64, 1160-1168DOI: (10.1016/j.jvs.2016.03.472) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 4 Zones and branches of the deep femoral artery. a, Artery. (Reproduced with permission from Veith FJ. Alternative approaches to the deep femoral, popliteal and infrapopliteal arteries in the leg and foot: part I. Ann Vasc Surg 1994;8:514-22.) Journal of Vascular Surgery 2016 64, 1160-1168DOI: (10.1016/j.jvs.2016.03.472) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 5 Direct approach for exposure of the middle and distal zones of the deep femoral artery (a). Inset shows incisions for the anteromedial approach (solid line) along the medial border of the sartorius muscle (m) and the anterior approach (dashed line) along the lateral border of the muscle. Both incisions are placed inferior to groin scarring. The sartorius muscle and superficial femoral vascular bundle are retracted laterally when the anteromedial approach is used and are retracted medially when the anterior approach is used. An incision is made in the fibrous union between the fascial sheaths of the vastus medialis and adductor longus muscles to expose the underlying deep femoral artery. Accompanying veins are always present and may overlie the artery. (Reproduced with permission from Veith FJ. Alternative approaches to the deep femoral, popliteal and infrapopliteal arteries in the leg and foot: part I. Ann Vasc Surg 1994;8:514-22.) Journal of Vascular Surgery 2016 64, 1160-1168DOI: (10.1016/j.jvs.2016.03.472) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 6 Direct approach for exposure of the middle and distal zones of the deep femoral artery (a). A, Incisions are shown for the anteromedial approach (solid line) along the medial border of the sartorius muscle (m) and the anterior approach (dashed line) along the lateral border of the muscle. B and C, Transverse sections of the middle third of the right thigh are shown as viewed from below. Relationships of muscles to superficial femoral and deep femoral vascular bundles are shown. The dashed arrow indicates a route for the anterior direct approach to the deep femoral artery made along the lateral border of the sartorius muscle with medial retraction of the superficial femoral vascular bundle. The solid arrow indicates an anteromedial approach with lateral retraction of the sartorius muscle and superficial femoral vascular bundle. C, A direct posteromedial approach to the deep femoral artery is shown. Access is gained between the adductor longus anteriorly and the adductor magnus and brevis posteriorly. Note complete separation of this approach from the superficial femoral vascular bundle and the subsartorial space. (Reproduced with permission from Veith FJ. Alternative approaches to the deep femoral, popliteal and infrapopliteal arteries in the leg and foot: part I. Ann Vasc Surg 1994;8:514-22.) Journal of Vascular Surgery 2016 64, 1160-1168DOI: (10.1016/j.jvs.2016.03.472) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 7 A, Incisions in the lateral aspect of the thigh and calf to gain access to the (B) above-knee and (C) below-knee popliteal artery, respectively (dashed line for above knee; solid line for below knee). m, Muscle; t, tendon. (Reproduced with permission from Veith FJ. Alternative approaches to the deep femoral, popliteal and infrapopliteal arteries in the leg and foot: part I. Ann Vasc Surg 1994;8:514-22.) Journal of Vascular Surgery 2016 64, 1160-1168DOI: (10.1016/j.jvs.2016.03.472) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 8 Lateral exposure of the above-knee popliteal artery (a) as described in the text. m, Muscle. (Reproduced with permission from Veith FJ. Alternative approaches to the deep femoral, popliteal and infrapopliteal arteries in the leg and foot: part I. Ann Vasc Surg 1994;8:514-22.) Journal of Vascular Surgery 2016 64, 1160-1168DOI: (10.1016/j.jvs.2016.03.472) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 9 Lateral exposure of the below-knee popliteal artery. The upper fourth of the fibula is shown before it is resected. Note the position of the common peroneal nerve (n), which must be protected from injury. m, Muscle. (Reproduced with permission from Veith FJ. Alternative approaches to the Deep Femoral, Popliteal and Infrapopliteal Arteries in the Leg and Foot: Part I. Ann Vasc Surg 1994;8:514-22.) Journal of Vascular Surgery 2016 64, 1160-1168DOI: (10.1016/j.jvs.2016.03.472) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 10 Lateral exposure of the below-knee popliteal artery (a) and its distal branches after removal of the upper portion of the fibula. n, Nerve; t, tendon. (Reproduced with permission from Veith FJ. Alternative approaches to the deep femoral, popliteal and infrapopliteal arteries in the leg and foot: part I. Ann Vasc Surg 1994;8:514-22.) Journal of Vascular Surgery 2016 64, 1160-1168DOI: (10.1016/j.jvs.2016.03.472) Copyright © 2016 Society for Vascular Surgery Terms and Conditions

Fig 11 Course of prosthetic bypass via a lateral thigh tunnel to the distal popliteal artery approached laterally. (Reproduced with permission from Veith FJ. Alternative approaches to the deep femoral, popliteal and infrapopliteal arteries in the leg and foot: part I. Ann Vasc Surg 1994;8:514-22.) Journal of Vascular Surgery 2016 64, 1160-1168DOI: (10.1016/j.jvs.2016.03.472) Copyright © 2016 Society for Vascular Surgery Terms and Conditions