Pre- and Postoperative Diagnosis:
Right popliteal artery occlusion with severe ischemia of the right foot.

Procedure: Right femoral to anterior tibial bypass graft with reverse saphenous vein. Completion arteriogram.

Anesthesia: General endotracheal intubation.

Description of Procedure:
With the patient under well tolerated general anesthesia in the supine position, both groins and the entire right lower extremity were prepped and draped in the usual sterile fashion. In the mid-portion of the anterior compartment of the right lower leg, a longitudinal incision was fashioned and carried down through the subcutaneous fascia. The anterior tibialis muscle was reflected medially, exposing the neurovascular bundle. The anterior tibial artery, which was free of side branches, was then gently dissected for a total length of 4 cm and controlled with Vesiloops.

Next, a longitudinal groin incision was made with the scalpel. The very proximal segment of superficial femoral artery was gently dissected free and controlled with Vesiloops.

The greater saphenous vein was identified in the groin and traced distally as it was harvested using electrocautery to control bleeding. Once the vein was harvested, it was dialated with a heparin and papaverine solution and inspected for any leaks or missed side branches. The harvest wound was then packed with a moistened lap pad and temporarily closed to protect it during the remaining portion of the procedure.

A dual component tunneler was then passed from the distal wound through the lateral aspect of the thigh and knee in the subcutaneous space to communicate with the groin dissection and femoral artery. 7000 units of intravenous heparin were then administered and, after waiting the three minute circulation time, the superficial femoral artery was clamped distally and proximally and an arteriotomy was fashioned.

The vein was placed in reverse fashion and the proximal tip was cut to the appropriate dimensions and sutured into position using running continuous suture of 5-0 Surgilene.

Flow was restored to the superficial femoral artery to the native circulation. A proximal clamp was then placed and the vein marked with a surgical marker to ensure that it was not twisted as it was carefully passed through the tunneling device. The anterior tibial artery was then occluded with microclips. An anterior tibial arteriotomy was fashioned, and the vein was cut to the appropriate dimensions and sutured with running continuous suture of 7-0 Surgilene. Prior to final placement of sutures, retrograde and prograde flushing were performed to ensure patency. There was an excellent pulse in the tibial artery as well as distally in the foot. The foot became pink and warm.

A completion arteriogram demonstrated no technical difficulties with the distal anastamosis and good flow through the distal portion of the graft, with runoff via the anterior tibial into the foot.

Suture line hemostasis was achieved with thrombin-soaked Gelfoam. All wounds were inspected and copiously irrigated with saline solution. The wounds were then closed in two layers using interrupted Vicryl for the deep layers and staples for the skin.

At the end of the case, all sponge and instrument counts were correct times two. The patient tolerated the procedure well and was transferred to the PACU in stable condition.