Editing Fem-pop occlusive disease (section)

=== Fem-pop bypass graft ===

* PFA supplies blood to thigh, SFA to leg via adductor canal
* SFA enters popliteal fossa at apex, where it becomes POPA
* CFV just medial to CFA in fem triangle, with GSV entering the CSV at fossa ovalis, and lymphatics medial to that.
** Note PFA generally posterolateral branch of CFA
*
* Below-knee POPA is variable in length before dividing into ATA (which travels laterally, enters anterior compartment, becomes DP) and TPT (branches into peroneal and PT, and enters deep posterior compartment)

GSV HARVEST

* Identify GSV in fem triangle. Incise directly over vein to avoid undermining. 
* Dissect periadventitial tissue away sharply. Ligate tributaries with silk (leave a short stump, don't narrow the conduit)
* Continue dissection distally until adequate length is obtained
* Place small clamp flush with GSV. Divide. Oversew stump with running monofilament.
* Preparation
** Place in a bath of heparinised saline and papaverine
** Clamp proximal end with small bulldog
** Flush heparinised saline from distal end
** Meticulously repair small tears
* Store in chilled, heparinised blood until ready to use

SSV HARVEST

* Best with patient prone
* Longitudinal incision posterior calf lateral to Achilles tendon
* Beware of sural nerve

SPLICING VEINS

* Spatulate
* Interrupted fine polypropylene sutures

FEM TO ABOVE KNEE POP BG

* Incision directly over CFA pulse and dissect down to femoral sheath, use self-retainers
** Expose CFA proximally to inguinal ligament
** Continue dissection distally to proximal SFA
** Identify and expose PFA
* AKP exposed from medial thigh - longitudinal incision anterior to sartorius and retract sartorius posterolaterally
* Divide deep fascia to expose popliteal fossa. Dissect and mobilise artery.
* Identify a healthy section of artery and place proximal and distal clamps
* Tunnel conduit - put clamps from groin to popliteal fossa in anatomical plane, and pull vein through
* Proximal anastamosis first, then distal

TO BELOW-KNEE POP

* Longitudinal incision 1-2cm posterior to medial edge of tibia
* Divide pes anserinus
* Mobilise medial head of gastrocnemius - expose pop fossa
* Dissect pop vein away from artery
* Anastamosis

INTRA-OP BYPASS GRAFT ASSESSMENT

* Confirm graft patency
* Establish integrity of conduit
* Confirm adequacy of outflow
* Identify potential conduit, anastomotic, technical defects that may predispose to thrombosis
* Doppler foot

WOUND CLOSURE

* Layers
* Skin edge eversion w/ nylon
* Drain in groin if concern for lymphatic leak