Femoral-Popliteal Bypass
Patient phenotype
60s-80s, severe PAD with rest pain, non-healing ulcer, or limb threat. Universal CAD, often diabetes, smoker, CKD, COPD. ASA III-IV.
Procedure
Vein (preferred) or prosthetic graft from femoral to above-knee or below-knee popliteal artery. Supine, leg externally rotated. ~3-5 hours. Heparinization during clamping.
Anesthetic plan
Choice of GETA, neuraxial, or combined. Neuraxial (epidural/spinal) provides sympathectomy = better graft flow, lower SSI, but harder to manage in long case + heparinization timing matters. Many do GETA + epidural for postop.
Setup
- ·A-line
- ·1-2 PIVs (16-18g)
- ·Type & screen (cross 2 units if redo)
- ·Heparin available (80-100 U/kg before clamp)
- ·Forced air warmer + fluid warmer
- ·Foley
Biggest concerns by phase
Cardiac risk dominates outcomes
PAD = CAD by definition. RCRI typically ≥ 2. Continue beta-blocker, statin, aspirin. Hold ACE/ARB. Stress test only if symptom change or unable to do prior.
Neuraxial timing with anticoagulation
ASRA: hold prophylactic LMWH 12h, therapeutic 24h. Heparin SQ → atraumatic neuraxial. Aspirin/Plavix usually continued. Document neuro before/after if epidural.
Hemodynamic management — keep MAP up
MAP > 70 (ideally > 80) for graft perfusion. Vasopressor preferred over fluid bolus. Avoid hypothermia (vasoconstriction = graft compromise).
Heparinization + ACT monitoring
Heparin 80-100 U/kg before clamp. ACT > 250 confirmed. Recheck q30 min. Protamine reversal at end variable. Watch for hypotension/anaphylaxis.
Graft occlusion early postop
Loss of distal pulse, pain, pallor = graft thrombosis, surgical emergency. Continuous distal pulse monitoring (Doppler) in PACU. MAP control critical.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
72-yo M, EF 40%, COPD, CKD Cr 1.7, on ASA + clopidogrel for prior CAD stents, 4-week rest pain. Fem-pop scheduled. GA, neuraxial, or combined?
What an examiner probes for
- ▹Considers DAPT timing + ASRA bleeding risk
- ▹Discusses sympathectomy benefit of neuraxial
- ▹Plans MAP target + hemodynamic management
- ▹Renal protective strategy
- ▹Postop pain control + early ambulation
Sources
- Miller's Ch 70
- ASRA Anticoagulation Guidelines 4e
Anatomy reference
Sourced reference images. 4 matches for "vessels arterial vein leg femoral".
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