Aortic Bifemoral (Aortobifemoral) Bypass Periprocedural Care

Updated: May 22, 2020
  • Author: Shabir Bhimji, MD, PhD; Chief Editor: Vincent Lopez Rowe, MD  more...
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Periprocedural Care

Patient Education and Consent

Patients who smoke should be asked to discontinue tobacco for at least 4 weeks before surgery.

Patients who are taking a nonsteroidal anti-inflammatory drug (NSAID) should be asked to stop the medication 5-7 days prior to the procedure. If the patient is taking warfarin, he or she should be admitted and started on heparin 2-3 days before surgery. The heparin should be discontinued at midnight before the day of the procedure.

Patients should be asked to discontinue all herbal products before the procedure.

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Preprocedural Planning

Patients with risk factors for heart disease should be cleared by the cardiologist. If the patient is a heavy smoker, a pulmonary consult should be obtained.

Laboratory evaluation should include the following:

  • Complete blood count (CBC)
  • Coagulation profile, including international normalized ratio (INR), prothrombin time (PT), and partial thromboplastin time (PTT)
  • Platelet count
  • Renal and liver function tests
  • Urinalysis
  • Chest x-ray
  • Electrocradiography (ECG)
  • Cross-matching and typing of 2 units of blood
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Patient Preparation

Aortic bifemoral (aortobifemoral) bypass is an extensive procedure that requires careful patient preparation. For elective surgery, the patient should not smoke for at least 3-4 weeks, and on the day of surgery, two to four units of packed red blood cells should be available. Autologous blood donation is recommended in most elective cases.

Adequate hydration is recommended before surgery, and an intravenous (IV) fluid drip should be started at midnight. A broad-spectrum antibiotic is administered just before the incision is made.

In most aortic bifemoral bypass procedures, blood transfusion can be avoided through proper hemostasis and careful dissection. A cell saver, if available, can help decrease the need for blood transfusions. [29]  Better still, autologous blood donation can be done 3 weeks in advance of elective surgery. Routine use of blood during aortic bifemoral bypass is not recommended. [3]

Anesthesia

Aortobifemoral bypass is an extensive procedure and requires general anesthesia. A central venous line is placed for monitoring and fluid access during anesthesia. A radial line is usually inserted for continuous monitoring of blood pressure. [29]

In patients with heart problems, a Swan-Ganz (pulmonary artery) catheter may be used to monitor cardiac function. Today, most patients are given a combination of spinal and general anesthesia. The epidural catheter is left in place for a few days to limit pain; this can significantly reduce exogenous narcotic requirements.

All fluids are warmed before administration, and the upper body is covered with a warming unit (eg, Bair Hugger). [3, 4, 5]

Positioning

For an aortic bifemoral bypass, the patient is placed in the supine position, with the arms extended at the side. The infrarenal aorta can be exposed via several different incisions, but the most common choice is a midline abdominal incision extending from the xiphoid to the pubis. [3, 4, 5, 30, 31]

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Monitoring & Follow-up

The 2018 guidelines from the Society for Vascular Surgery (SVS) recommended clinical examination and ankle-brachial index (ABI) measurement, with or without the addition of duplex ultrasonography (US), in the early postoperative period to provide a baseline for further follow-up after aortobifemoral bypass; this evaluation would be repeated at 6 and 12 months and then annually as long as there are no new signs or symptoms. [32]

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