Femoro-Femoral Bypass Graft

The femoral-femoral bypass graft connects the femoral arteries via a graft. It is usually performed due to an occlusion above the placed graft, enabling blood supply to the lower extremity.

Presenting symptoms

Ischemic lower extremity - may see gangrene, ulceration, or pain at rest

It may be used to alleviate functional ischemia associated with claudication or exercise

Patients may present with a history of severe PVD, CAD, HTN, COPD, and DM

Three types of occlusive vascular disease

Type 1 - isolated to the aortic and iliac bifurcations

• No CAD

Type 2 - diffuse pattern involving coronary and cerebral circulations

• Higher incidence of HTN, DM

Type 3 - involves small vessels, especially lower limbs

Surgical procedure

Graft placed between unobstructed inflow source - common femoral, superficial, or deep femoral artery to target artery

Organ Considerations

Respiratory

Vascular patients often have a history of smoking and COPD

May have pulmonary function testing done preop to evaluate pt for GA versus regional

Cardiovascular

May see elevated morbidity and mortality if there is a history of CAD and HTN

Monitor ECG for LVH (Peaked R waves)

Neurological

May have cerebrovascular disease

• Document any deficits

Endocrine

DM associated with peripheral and autonomic neuropathies, silent MI, delayed gastric emptying

Check blood glucose as needed

Renal

There is a higher incidence of renal artery disease and renal insufficiency in this population

Check BMP

Hematologic

Ask about bruising tendency

May be on anti-platelet medication

Check CBC, PT, PTT

Position

Supine position

Keep the head in a neutral position

Massage/reposition the head during lengthy procedures to prevent alopecia

Heels off mattress for more prolonged procedures

Decreased FRC and HR

Increased venous return, leading to increased preload and CO

Increased intraabdominal pressure

Zone 3 (a-v-A) in the dorsal portion of the lungs

CNS: blood/cerebrospinal fluid drainage is gravity-dependent, valve-less

When supine = increased ICP, which decreases cerebral perfusion pressure (CPP= MAP-ICP/or CVP)

BMI elevated - decreased FRC. Difficulty maintaining tidal volumes due to body weight pressing down on the chest

Padding: Protect pressure points. Arms either with hands supinated <90degree (prevent Brachial Plexus injury from stretch) or alongside with hands facing body. Pad to prevent ulnae nerve injury. Possibly place a pillow under the knees if there is a history of back pain, maintain the lordotic curve in the spine, and prevent tension on the sciatic nerve. Prevent alopecia with padding of the head

Check eyes - always tape them to prevent corneal abrasion

Preoperative Considerations

Antibiotics

Cefazolin as per surgeon

Surgical time

2-3 hrs

EBL

200-300 mL

Age range

>55 yr, male: female 4:1

Morbidity

MI - 5-12%, respiratory insufficiency 5%, infection 2-5%, amputation 2-4%, CVA <1%

Mortality

2-4%    

Pain score

4-6

Anesthetic considerations

Preoperatively

Pt ID, verify consent, NPO, history, allergies, airway assessment, and medications. Review chart. Type and screen - possible type and cross?

Questions answered

Consider GETA vs. epidural depending on the history

Have NTG and Neo drips in the room

Monitors

Pulse ox, ECG (II for dysrhythmias, V5 for ischemia), NIBP, Temp

2 large bore IVs

A-line?

Fluid warmers?

Bair huggers upper

Foley - U/O > 0.5 mL/kg/hr

Heparin 50-100 units/kg given IV before catheter manipulation

• Monitor ACT to prevent blood clots

Induction - GETA                      

Hemodynamic stability is essential - slow, gradual induction (avoid ischemia)

Preoxygenation

Zemuron 5 mg IV to minimize myalgias from Succinylcholine

Lidocaine 1 mg/kg/IV

Propofol 1-2 mg/kg/IV – if cardiac history, use Amidate 0.2-0.4 mg/kg/IV (2mg/mL vial)

Fentanyl 1-3 mcg/kg/IV

Succinylcholine 0.5-1.5 mcg/kg/min

Tape eyes as soon as eye lash reflex is gone, then intubate

Epidural

This addition can be used for post-op pain management - lidocaine 2% with 1/200,000 epinephrine or 0.5% bupivacaine is used. Titrate to the required level (T8-T10)

Maintenance

Consider modified hypotension to minimize bleeding, monitor ACT

Isoflurane - if smoker consider Sevo (less irritant)

Fentanyl

Start Hydromorphone for post-op pain management 0.5-2 mg (0.01-0.04 mg/kg)

Emergence

Prevention of HTN and tachycardia

Esmolol to control tachycardia on emergence

• 25-100 mg (0.5-2.0 mg/kg) May repeat every 5 min. (10 mg/mL)

Zofran 4 mg

Reverse Heparin if needed, with protamine 1 mg/100 units of heparin

• Watch for protamine reaction
  • HOTN
    • Histamine release and vasodilation
  • Anaphylactoid reaction
    • History of fish allergy, vasectomy, prior exposure (NPH insulin or surgery)
  • Severe pulmonary vasoconstriction
  • HOTN, increased pulmonary artery pressures, right heart failure

Complications

HTN, hypothermia (causes vasoconstriction), hemorrhage