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CHAPTER 86 • Femorotibial and Peroneal Bypass 931

Incision

Posterior Tibial Artery Mid Calf

Cross-section

Soleus muscle

Anterior tibial artery and vein,

deep peroneal nerve

Tibialis anterior muscle

Extensor hallucis longus muscle

Extensor digitorum longus muscle

Peroneus brevis muscle

Fibula

Peroneus longus muscle

Flexor hallucis longus muscle

Peroneal artery and vein

Small saphenous vein

Great saphenous vein

Tibia

Tibialis posterior muscle

Tibial nerve

Gastrocnemius muscle

Posterior tibial

artery and veins

Flexor digitorum muscle

Soleus muscle

Posterior tibial

artery

Flexor digitorum

longus

Flexor digitorum

brevis

Flexor

retinaculum

FIGURE 86–1

932 Section XII • Vascular

THE ANTERIOR TIBIAL ARTERY

◆ The ATA is isolated through an incision on the lateral calf between the tibia and ﬁ bula

(Figure 86-2, A). Sometimes in thin legs, you can appreciate the division between the ante-

rior and lateral compartments of the leg and guide your incision more toward the anterior

compartment. In the proximal leg, a plane can be developed between the tibialis anterior

and extensor digitorum longus muscles (Figure 86-2, B). The artery, vein, and nerve

(deep peroneal) will be just anterior to the interosseus membrane. Once again there will be

a rich network of surrounding veins.

◆ By the mid-portion of the leg, the extensor hallucis longus muscle originates and becomes

more prominent, and the plane will be between it and the anterior tibialis muscle.

◆ In the distal third of the leg, the ATA courses much more anteriorly and is found between

the tendon of the tibialis anterior muscle and the extensor hallucis longus muscles.

◆ The challenge with the ATA, however, is how to tunnel the vein graft. The two most popu-

lar options include an anatomic location with it going through the interosseus membrane in

the popliteal space and then laterally in the anterior compartment. The other is to have the

vein in a modiﬁ ed in situ position that courses from a medial to lateral position just below

the skin. If the origin of the bypass is the femoral artery and it courses along the lateral

knee, great care must be taken to account for the knee bending. If the origin of the bypass

is the popliteal, then the options include laying it on top of the tibia or removing a section

of the bone to allow it to sit better. Either way, if this approach is used, extra length of vein,

which may not be available, is required.

CHAPTER 86 • Femorotibial and Peroneal Bypass 933

Tibialis posterior

muscle

Tibia

Saphenous vein

and nerve

Soleus muscle

Gastrocnemius

muscle

Tibialis anterior

muscle

Extensor digitorum

longus muscle

Peroneus longus muscle

Deep peroneus nerve,

anterior tibial artery and vein

Peroneal artery and vein

Fibula

Posterior tibial artery and vein,

tibial nerve

Small saphenous vein

Tibia

Incision

Anterior tibial artery

Fibula

Posterior Tibial Artery Mid Calf

FIGURE 86–2

934 Section XII • Vascular

THE PERONEAL ARTERY

◆ The peroneal artery is the most difﬁ cult tibial artery to work with. It is always much deeper

than expected. In a thin calf, the peroneal artery is generally approached medially. The same

general dissection is used as for the PTA, but you must go deeper for the peroneal artery. The

soleus is again divided and retracted posteriorly toward the OR table (Figure 86-3). The

PTA is left in its loose areolar tissue with the soleus muscle. The peroneal artery will be

located on the anterior surface of the ﬂ exor hallucis longus. This makes sewing the distal

anastomosis more challenging because seeing and sewing in a small deep space is more

difﬁ cult.

Fibula

Flexor hallucis

longus muscle

Peroneus longus muscle

Tibialis posterior

muscle

Tibia

Tibialis anterior

muscle

Extensor digitorum

longus muscle

Deep peroneal nerve,

anterior tibial artery and vein

Peroneal artery and vein

Posterior tibial artery and vein,

tibial nerve

Saphenous vein

and nerve

Small saphenous vein

Medial Approach Peroneal Artery

Soleus

muscle

Soleus

muscle

Gastrocnemius

muscle

Gastrocnemius

muscle

FIGURE 86–3

CHAPTER 86 • Femorotibial and Peroneal Bypass 935

Peroneal artery

Lateral Approach Peroneal Artery

Tibialis anterior muscle

Tibia

Soleus

muscle

Soleus

muscle

Gastrocnemius

muscle

Gastrocnemius

muscle

Tibialis posterior muscle

Peroneal artery and vein

Peroneus longus muscle

Fibula resected

Extensor digitorum

longus muscle

Deep peroneal nerve

Anterior tibial artery and veins

Posterior tibial artery and veins,

tibial nerve

FIGURE 86–4

◆ If a leg is large or if the peroneal artery is best very distally in the leg, the artery can be approached

laterally with removal of a section of the ﬁ bula (Figure 86-4).

936 Section XII • Vascular

STEP 4: POSTOPERATIVE CARE

◆ Most patients undergoing surgery for peripheral arterial disease have multiple comorbidities

including coronary artery disease. They can be monitored in an intensive care unit, step-down

unit, or specialized ﬂ oor bed depending on the protocols of the institution. Minimum

requirements should include telemetry, and vital signs should be taken every 2 hours, includ-

ing monitoring patency of the graft with Doppler ultrasonography. It is important to educate

staff on the importance of using a quantitative measure, such as a Doppler signal, and not

relying on an individual’s experience at feeling pedal pulses.

◆ If medically stable, the patient should be moved to a ﬂ oor bed as soon as possible. Rehabili-

tation therapy should begin immediately, even if it is as simple as sitting in a chair. Realistic

expectations should be discussed with the family and staff about discharge planning. Many

patients will need transition care either in a rehabilitation facility or a skilled nurse facility

(SNF) before they are independent and can go home by themselves or with a caregiver.

◆ The need for postoperative modulation of the coagulation cascade is greater the longer the

bypass is. Postoperatively, many surgeons prescribe a nonadjusted unfractionated heparin

intravenous drip for 12 to 24 hours. It is common to prescribe either an anticoagulant

(warfarin) or a platelet inhibitor (aspirin or clopidrogel) after that. The decision on which

one to use needs to be individualized based on certain factors. In general, these include

quality of the inﬂ ow, which should be adequate before attempting an infrainguinal proce-

dure. The outﬂ ow artery may not always be ideal, or a bad vein may convince the surgeon

to use a stronger agent. Most surgeons try to avoid prosthetic conduits (ePTFE) below the

knee, but if it is used, warfarin is generally used.

◆ After discharge, the patient should be seen in the clinic and understand that he or she will

have a relationship with the surgeon for the life of that graft. Routine graft surveillance with

duplex scanning and ankle-brachial indices (ABIs) has been demonstrated to increase the pri-

mary patency of grafts (assisted primary patency). Protocols include a postprocedure baseline

level and close follow-up (every 3 months for a year, then biannually). A drop in the ABI or a

velocity elevation is suggestive of a stenosis in the graft and warrants an arteriogram and pos-

sible intervention.

STEP 5: PEARLS AND PITFALLS

◆ Femorotibial reconstruction is an excellent option for patients with advanced occlusive disease,

most of which present with critical limb ischemia (rest pain or tissue loss). These individuals

have a larger burden of disease and tend to have other serious comorbidities, such as cardiac

disease and long-standing diabetes. They are more likely to have an adverse clinical event in

the perioperative period. Great care must be taken to limit the risk of this, and such treatment

as perioperative beta blockade is essential for this group.

◆ Just as in the in situ femoropopliteal reconstruction, the tibial bypass is also at risk for

wound complication issues. Great care with tissue handling, keeping the graft as deep as

possible, and avoiding a ﬂ ap creation are essential to promote good wound healing.

CHAPTER 86 • Femorotibial and Peroneal Bypass 937

SELECTED REFERENCES

1. Ouriel K, Rutherford R (eds): Atlas of Vascular Surgery: Operative Procedures. Philadelphia, Saunders,

1998.

2. Norgren L, Hiatt WR, Dormandy JA, et al: Inter-Society Consensus for the Management of Peripheral

Arterial Disease (TASC II). J Vasc Surg 2007;45:S5-S6.

3. Valentine RJ, Wind GG: Anatomic Exposures in Vascular Surgery, 2nd ed. Philadelphia, Lippincott

Williams & Wilkins, 2003.

4. Rutherford RB: Atlas of Vascular Surgery: Basic Techniques and Exposures. Philadelphia, Saunders, 1993.

938

STEP 1: SURGICAL ANATOMY FOR FOREARM

◆ The forearm is divided into multiple fascial compartments, each containing several mus-

cles that are additionally enclosed within individual epimysial envelopes. Three forearm

compartments are usually described: the volar, dorsal, and lateral (mobile wad)

compartments.

◆ The interosseous membrane separates the volar and dorsal compartments from each other,

and the posteriorly and radially located lateral compartment is demarcated by a connective

tissue septum from the antebrachial fascia. In most cases of compartment syndrome, the

volar muscles are the most severely affected, followed in severity by the muscles of the dor-

sal compartment and of the lateral compartment. Some communication exists among the

three main compartments, and release of the volar compartment often relieves elevated tis-

sue pressure in the dorsal compartment. Intraoperative pressure measurements and clinical

ﬁ ndings may preclude the need for a separate dorsal fasciotomy to relieve this extensor

compartment. The lateral compartment musculature is superﬁ cial and easily decompressed.

◆ Within the volar compartment, additional distinction can be made between the superﬁ cial

and deep muscles. The superﬁ cial muscles include the pronator teres, palmaris longus,

ﬂ exor digitorum superﬁ cialis, ﬂ exor carpi radialis, and ﬂ exor carpi ulnaris. The deep

muscles include the ﬂ exor digitorum profundus, ﬂ exor pollicis longus, and pronator

quadratus. The ﬂ exor digitorum profundus and ﬂ exor pollicis longus are particularly vul-

nerable in compartment syndrome, because they may be compressed against rigid bone and

the unyielding interosseous membrane. Anatomic and clinical reports demonstrate that

release of the superﬁ cial volar compartments may not be adequate to relieve deep pressures

in these muscles.

◆ The dorsal compartment is also divided into superﬁ cial and deep muscles. The extensor

digitorum, extensor carpi ulnaris, and extensor digiti minimi are the superﬁ cial group,

which lie in a plane above the deeper abductor pollicis longus, extensor pollicis brevis, ex-

tensor pollicis longus, extensor indicis, and supinator (Figure 87-1, A).

CHAPTER

Fasciotomy—Forearm and Leg

William J. Mileski

CHAPTER 87 • Fasciotomy—Forearm and Leg 939

FIGURE 87 –1

Palmaris longus muscle

Flexor digitorum superficialis muscle

Basilic vein

Flexor carpi ulnaris muscle

Ulnar nerve

Flexor digitorum profundus muscle

Common interosseous artery

Ulna bone

Anconeus muscle

Extensor carpi ulnaris muscle

Posterior cutaneous nerve

of forearm from radial nerve

Anterior branch of medial

cutaneous nerve of forearm

Flexor carpi radialis muscle

Pronator teres muscle

Median antebrachial vein

Brachioradialis muscle

Radial artery

Extensor carpi radialis longus muscle

Cephalic vein

Extensor carpi radialis brevis muscle

Supinator muscle

Extensor digitorum muscle

Extensor digiti minimi muscle

Right Forearm

Lateral

Right Forearm

Medial

Volar incision

Superficial volar

compartment

Deep volar

compartment

Superficial

dorsal compartment

Lateral compartment

Deep dorsal

compartment

940 Section XII • Vascular

STEP 2: PREOPERATIVE CONSIDERATIONS FOR FOREARM

◆ Compartment syndrome is a surgical emergency that usually requires release of the superﬁ -

cial muscle compartments. In some clinical situations, it is imperative to also explore the

deep muscle compartments.

◆ Forearm compartment syndrome requires immediate evaluation and treatment. The need

for operation is established by careful review of the patient’s history; the presence of physi-

cal signs and symptoms, such as pain with passive stretching, paresthesias, paresis, and

palpably tense compartments; and, if needed, the measurement of elevated compartment

pressures (⬎30 cm H

O).

◆ The treatment of compartment syndrome requires expedient fasciotomy when nonoperative

maneuvers such as cast removal are unsuccessful. If left untreated, elevated tissue pressure

within the fascial conﬁ nes decreases capillary blood perfusion below a level necessary for

soft tissue viability. Most patients ultimately have minimal limb dysfunction when fasciot-

omy has been performed promptly and to an adequate depth. Postoperative loss of function

may be caused by several factors, including damage from the initial injury, ischemia caused

by elevated tissue pressure before fasciotomy, inadequate fasciotomy, and iatrogenic surgical

injury.

◆ Mandatory exploration of deep muscle compartments is indicated in situations in which the

deep muscles are preferentially injured, such as in cases of high-voltage electrical injury.

The high electrical resistance of bone transmits a signiﬁ cant thermal injury to the adjacent

muscles of the deep compartment. Other conditions that require exploration of the deep

spaces include severe crush injuries; situations involving extended pressure, such as an

unconscious patient lying on the limb; and when there is ongoing sepsis or suspicion of

necrotic muscle, despite previous fasciotomy. If epimysiotomies of the deep muscles are not

performed in these situations, necrosis and contracture may result.

◆ Limited incisions to minimize collateral morbidity from fasciotomy do not offer access to all

components and increase the potential for missing an ischemic or necrotic muscle group.

STEP 3: OPERATIVE STEPS FOR FOREARM

1. INCISION

◆ A commonly used approach, begins 1 cm proximal and 2 cm lateral to the medial epicon-

dyle. The incision is carried obliquely across the antecubital fossa and over the volar aspect

of the mobile wad and is then curved medially to reach the midline of the forearm at the

junction of its middle and distal thirds. The incision is continued straight distally to the

proximal wrist crease ulnar to the tendon of the palmaris longus and is ﬁ nally curved across

to the midpalm (Figure 87-1, B).