Infrainguinal arterial bypass

Infrainguinal arterial bypass

Anesthesia type	General
Airway	ETT
Lines and access	Large bore IV x2 Arterial line
Monitors	Standard ABP
Primary anesthetic considerations
Preoperative	Evaluate for CAD, HTN, DM
Intraoperative	Ischemia-reperfusion syndrome after cross clamp removal Lactic acidosis ATN Hyperkalemia
Postoperative
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Infrainguinal arterial bypass procedures include:

• Aortofemoral bypass or aortobifemoral bypass
• Axillofemoral bypass or axillobifemoral bypass
• Femorofemoral bypass (fem-fem)
• Femoral popliteal bypass (fem-pop)
• Femoral tibial bypass (fem-tib)

Overview

Indications

Severely PAD causing claudication, ulceration, or infection

Surgical procedure

• Incision of bypass sites (source and target arteries)
• ± Harvest of vein graft
• Anastomotic tunnel creation
• Clamp of proximal artery
• Distal anastomosis, then proximal anastomosis
• Reperfusion of arteries
• Arteriogram to confirm flow

Preoperative management

Patient evaluation

System	Considerations
Airway
Neurologic	Peripheral neuropathy
Cardiovascular	Significant PAD, usually also CAD (prior MIs), HTN
Pulmonary
Gastrointestinal
Hematologic
Renal	Possible comorbid CKD
Endocrine	Usually DM
Other

Labs and studies

• BMP to evaluate potassium, creatinine
• Coagulation factors (INR, PTT)

Operating room setup

• Arterial line setup
• Lead for intraop arteriogram
• Heparin and protamine prepared for clamp/unclamping

Patient preparation and premedication

• Anxiolysis as indicated

Regional and neuraxial techniques

• Spinal or epidural can be considered for intraoperative and postoperative pain control
  • There is some evidence that regional anesthesia promotes graft survival [citation needed].

Intraoperative management

Monitoring and access

• 2 large bore IVs for possible fluid/product resuscitation
• Arterial line for ABP

Induction and airway management

General anesthesia with ETT. Induce with paralysis

Positioning

• Supine

Maintenance and surgical considerations

• Clamping of large arteries may produce afterload increase, though usually minimal effect
• Unclamping of large arteries may induce ischemia-reperfusion syndrome (lactic acidosis, hyperkalemia, ATN)
• Heparin is needed during anastomosis creation
• Protamine may be needed for reversal at end of case

Postoperative management

Disposition

IMC vs. ICU

Pain management

If regional anesthetic used, epidural may be redosed.

Consider lower extremity nerve blocks for acute pain in the PACU (femoral, sciatic, popliteal blocks)

- Take care to check ASRA guidelines prior to any regional anesthesia in the patients.

Potential complications

• Arterial thrombosis/occlusion
• Acute cardiac event
• Wound hematoma
• Compartment syndrome

Procedure variants

	Variant 1	Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications