Axillofemoral Bypass Periprocedural Care

Updated: Aug 30, 2016
  • Author: Cheong Jun Lee, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
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Periprocedural Care

Preprocedural Evaluation

Preoperative workup is essential to confirm ischemia-related claudication, rest pain, and tissue loss. Screening should begin with the ankle-brachial index (ABI). Perform at least one imaging study for assessment: computed tomography angiography (CTA) of the aorta and lower-extremity arteries, magnetic resonance angiography (MRA), or standard aortography with assessment of runoff (outflow) vessels in the lower extremities. Patients should undergo preoperative cardiopulmonary assessment; progressive and symptomatic peripheral arterial disease likely signifies underlying cardiovascular disease.

Preoperative assessment of bypass inflow should begin with bilateral brachial blood pressure measurements to identify potential problems with the axillary or subclavian arteries. Choose the axillary artery on the side with the higher blood pressure if there is a systolic pressure discrepancy of 10 mm Hg or more between the limbs. If it will be necessary to access the thoracic aorta in the future, perform the bypass graft tunneling on the right side.

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Equipment

Equipment employed for axillofemoral bypass includes the following:

  • Standard vascular clamps and instruments
  • Tunneling device (eg, Gore tunneler; W. L. Gore and Associates, Flagstaff, AZ)
  • Polytetrafluoroethylene (PTFE) or Dacron-based aortic grafts (6-10 mm) of appropriate length and configuration for either a unifemoral or a bifemoral reconstruction
  • Doppler ultrasonography device to assess blood flow intraoperatively
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Patient Preparation

Anesthesia

Axillofemoral bypass is most often performed with general anesthesia because exploration of the axillary artery and tunneling of the graft proximal from the chest to the distal femoral landing site can be difficult to tolerate. In cases where underlying cardiopulmonary disease precludes general anesthesia, the procedure can be performed by using local anesthesia with sedation.

Positioning

Perform the procedure with the patient supine, and prepare a wide sterile field from the neck to the anterior thigh (with the chest, flank, and abdomen included). Place a rolled towel under the ipsilateral torso to allow good visualization of the lateral chest wall during tunneling of the graft. Prepare the donor arm in a sterile fashion, allowing for intraoperative abduction of the limb to assess for graft lie after the axillary anastomosis.

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Monitoring & Follow-up

The utility of routine graft surveillance with duplex ultrasonography has not yet been proved, and limited data are available on whether noninvasive scanning is truly able to identify a threshold predictive of impending bypass failure. Follow-up with standard ABI assessment at regular intervals is recommended.

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