This document summarizes the key steps for a fem-distal bypass procedure, including: 1) preoperative arteriogram and vein mapping, 2) dissection of the femoral artery and preparation of the vein graft, 3) tunneling of the graft through the leg, 4) anastomosis of the graft to the femoral artery proximally and distal artery, and 5) post-operative care including staple removal and follow-up arterial exams.

1. Fem-distal Bypass Josh Wilensky

2. 1. Preop Arteriogram Vein mapping

3. 2. Inflow Dissection Vertical incision over femoral pulse CFA, PFA, SFA circumferentially dissected out with vessel loops PFA dissected to bifurcation/trifurcation Crossing veins of PFA ligated

4. Inflow Dissection

5. 3. Outflow Dissection

6. 3. Outflow Dissection

7. 4. Vein Harvest Ipsilateral GSV with skip incisions Distended with heparinized saline Side branches ligated with 4-0 silk Reversed vs Non-reversed Non-reversed – better size match

8. 5. Tunneling - Anatomic location umbilical tape is left in the tunnel distal end of the vein is tied with a 2–0 silk tie to the tunneling device and passed back through the previously made tunnel

9. 6. Heparin 10,000 units of heparin

10. 7. Anastomosis Proximal: 6-0 running prolene end-to-side Distal: 7-0 interrupted prolene end-to-side

11. 8. Arteriogram Check feet for pulses and signals Completion arteriogram Cannulate CFA with 20-gauge butterfly needle

12. 9. Wound Closure Wounds closed in layers with 3-0 vicryl Skin with staples

13. 10. Post op Staples out in 2 weeks ABIs in 6 weeks Q 6mo ABIs