Lateral approach to the popliteal artery

Transcription

1 Lateral approach to the popliteal artery Frank J. Veith, M.D., Enrico Ascer, M.D., Sushil K. Gupta, M.D., and Kurt R. Wengerter, M.D., New York, N.Y. Techniques for exposure of the popliteal artery via lateral approaches above and below the knee are described. These techniques were used successfully in 21 patients who required secondary arterial reconstructions in the presence of extensive scarring, infection, or both in the standard medial access routes. (J VAse St3RG 1987;6: ) Surgical access to the popliteal artery for the management of traumatic injuries and aneurysm resection has been achieved for many years via a posterior approach. More recently, medial approaches both above and below the knee have gained wide acceptance for most arterial reconstructions involving the popliteal artery. As secondary operations on the popliteal artery are required more frequently, it is increasingly common to encounter patients in whom the standard surgical approaches to this artery are rendered difficult or impossible because of extensive surgical scarring or persistent infection in a previous incision. The purpose of this article is to describe lateral approaches to the above-knee and below-knee popliteal artery. Although these approaches are particularly advantageous for secondary operations, the ease of their performance and the excellence of the exposure they provide also render them useful in other circumstances. SURGICAL TECHNIQUES Above-knee popliteal artery. The popliteal ar- ~cry above the knee joint is approached with a lateral incision between the iliotibial tract and the biceps femoris muscle (Fig. 1). By deepening the incision in the lateral intermuscular septum the popliteal space is entered and the neurovascular bundle can be palpated within the popliteal fat. The popliteal artery is easily isolated from the adjacent popliteal vein or veins, taldng care not to injure the common peroneal nerve (Fig. 2). After the popliteal artery is dissected from these structures, gentle traction with silicone Vesseloops can elevate it close to the skin level where surgical manipulation and anastomosis can be carried From the Division of Vascular Surgery, Montefiore Medical Center--Mbert Einstein College of Medicine. Supported in part by a grant from the Manning Foundation. Reprint requests: Frank J. Veith, M.D., Division of Vascular Surgery, Montefiore Medical Center--Albert Einstein College of Medicine, 111 East 210th St., New York, NY out with the same ease as is usual through the standard medial approach. Below-knee popliteal artery. This is approached via a lateral incision over the head and proximal fourth of the fibula (Fig. 1). This incision is deepened through the subcutaneous tissue and superficial muscular attachments to the fibula, taking care to identify the common peroneal nerve as it courses around the neck of this bone (Fig. 3). This nerve is dissected free so that it can be retracted and protected from injury. The biceps femoris tendon is divided. The ligamentous attachments of the fibula head are incised and the upper fourth of the fibula freed bluntly from its muscular and ligamentous attachments, staying as close to the bone as possible. After a retractor is placed deep to the fibula to protect underlying structures, one or two holes are drilled in this bone at its proposed site of transection. With such holes, a rib shears can cleanly transect the bone without leaving sharp spicules. After the bone is divided, any remaing deep attachments can be exposed and cut. With the upper fibula removed the entire below-knee popliteal artery, tibioperoneal trunk, anterior tibial artery, and the origins of the peroneal and posterior tibial artcries lie just deep to the excised bone and can easily be dissected from their adjacent veins (Fig. 4). After mobilization these arteries are more superficial in the wound than via standard medial approaches and surgical manipulation and anastomotic suturing can be performed with greater ease. Tunneling for grafts. To conduct grafts to or from a popliteal artery that is approached laterally, tunnels are constructed in a subcutaneous plane. For grafts from the femoral arteries approached via a standard groin incision, the course should be across the anterior aspect of the midthigh and then down the lateral aspect of the lower thigh to the popliteal fossa. If the external lilac artery, the axillary artery, or the thoracic aorta provides graft inflow, the tunnel follows a gradual curve from the inflow artery to the 119

2 120 Veith et al. VASCULAR. SURGERY M m W - r -?.z~..: Fig. 1. Incisions in lateral aspect of thigh and calf to gain access to above-knee and belowknee popliteal artery, respectively. lateral aspect of the thigh and then inferiorly to the popliteal fossa (Fig. 5). RESULTS The clinical experience with these techniques involved 21 patients and extended from January 1977 to December A lateral approach to the popliteal artery above the knee was used in 11 patients for secondary arterial reconstructions. In six cases the artery was used for prosthetic bypass outflow. Two of these bypasses originated from the axillary artery and two from the descending thoracic aorta in patients whose previous groin and medial popliteal incisions were complicated by infection. In the remaining two cases the bypass originated from the external iliac or common femoral artery. In five patients the above-knee popliteal artery was approached laterally to provide the inflow for a secondary bypass to the infrapopliteal arteries. Four of these were performed with autologous vein, one with a polytetrafluoroethylene graft. In all five cases the medial approach to the popliteal artery had been complicated by scarring and in three by infection as well. A lateral approach to the below-knee popliteal artery was used in 10 patients undergoing secondary revascularization. In four cases this approach was used to provide bypass outflow. In one of these pa- tients with groin and medial thigh and leg infection the bypass originated from the descending thoracic aorta; in two other similar patients the bypass originated from the axillary artery or the external iliac artery approached above the inguinal ligament. In the fourth patient the bypass originated from the common femoral artery. In six other patients, the below-knee popliteal artery was approached laterally to provide bypass inflow. Previous medial infection had been present in five of the six cases. In all s i ~'' patients the bypass extended to a tibial or peroneal artery, and in all it was performed with autologous vein. In three of these operations the lesser saphenous vein was harvested through a posterolateral incision. By raising a short lateral flap in the subcutaneous plane, the vein harvest incision was also used to gain access to the lateral aspect of the fibula. With the techniques already described, it was then possible to remove proximal and distal segments of the fibula to provide access to the popliteal artery for bypass inflow and an infrapopliteal artery for bypass outflow. Despite the high incidence of previous wound infection in these patients (16 of 21), none had a graft infection. Although the number of operations is too small and the experience too heterogeneous to permit statistical analysis of bypass patency in this group of patients, it did not appear to differ greatly

3 Volume 6 Number 2 August 1987 Lateral approach to the popliteal artery 121 Fig. 2. Lateral exposure of above-lmee popliteal artery. from patency in our comparable primary bypasses performed through standard medial approaches. DISCUSSION Popliteal artery aneurysms were first excised via a posterior approach and this route is still advocated by some surgeons for the treatment of popliteal entrapment syndromes because it helps to identify the pathologic anatomy more effcctivdy. 1 Because the ' sterior approach to the popliteal artery is usually carried out with the patient in the prone position, it renders harvest ofautologous greater saphenous vein somewhat awkward and makes access to the common and superficial femoral arteries difficult. Therefore, medial approaches to the popliteal artery, which can be performed with the patient in a supine position, have emerged as the standard route of access to the popliteal artery for occlusive disease or aneurysm. 2,3 Arterial bypass operations to or from the popliteal artery have now become well established to treat limb-threatening lower extremity ischemia. Many of these arterial reconstructions will fail with time, resuiting in renewed jeopardy to the limb and the need for some form of secondary operation. 4,s Secondary surgical access to the popliteal artery is often required and rendered difficult because of extensive surgical scarring or persistent infection in the usual ap- proaches to this vessel. In such circumstances, the techniques described herein provide access to all portions of the popliteal artery through totally uninvolved, virginal tissue planes. This greatly facilitates secondary operations and minimizes the risk of infection, which is more common when infrainguinal arterial reconstructions are performed through reopened wounds than when they are performed through previously unused access routes. 6 Moreover, in some instances previously undissected segments of popliteal artery may be reached more easily by these lateral approaches. Lateral approaches to the popliteal artery may also be advantageous for primary arterial reconstructions in several circumstances. In patients who have only a limited length of usable vein and who require a lateral approach to a tibial or peroneal artery for bypass outflow, a lateral popliteal approach will minimize the length of vein required. This was the case in two of our patients. In patients who have had a previous ttmaor and heavily irradiated skin and soft tissues along the medial aspect of the knee, the lateral approach may permit access to the popliteal artery via less heavily irradiated tissue. The lateral approach may also be advantageous in patients who require an urgent revascularization when the medial aspect of the knee is involved by coincidental infection. Finally,

4 122 Veith et al Journal of VASCULAR SURGERY (Jl~ m. ~x3}tr ~r~mvd5 m, Fig. 3. Lateral exposure of upper fourth of fibula before its resection. Note position ofconmaon peroneal nerve, which must be protected from injury. - "Biceps fendon (fronsecfed) i i,,,,,,,,,, Common peroneol nerve!... Periosfeum of resecfed fibula orfery Fig. 4. Lateral exposure of below-knee popliteal artery and its distal branches after removal of upper portion of fibula. the lateral approach is advantageous when simultaneous access to the below-knee popliteal artery and first several centimeters of the anterior tibial artery is required because superior exposure Of these two vessels is provided by fibular resection, particularly if the patient has a heavily muscled calf. Other investigators have previously described lateral surgical approaches to the neurovascular strv;*~

5 Volume 6 Number 2 August 1987 Lateral approach to the popliteal a~ery 123 Groff in subcufar~e~as funnel Lotemt P~fcdh= i,0,.,,,, :~, ~,~*\!,,~" ~-~\~"!~I, ~ ~,q { Fig. 5. Course of prosthetic bypass via lateral thigh runnel to distal popliteal arteh approached laterally. narcs in the poplitcal fossa and the leg. Henry, r in his book on extensile exposure, describes a technique to protect the neurovascular structures in gaining access to the popliteal surface of the femur via a lateral approach. Our approach to.the above-knee poplitcal artery was to a great extent based on his description. Elkin and Kelly* and later Danese and Singer 9 described lateral approaches with fibula resection to gain access to the distal branches of the popliteal artery. Elkin and Kelly used this approach for the i.imary treatment of arteriovenous aneurysms of the tibial and peroneal arteries; Danese and Singer, for anterior tibial bypasses. Our techniques represent an extension of these earlier approaches and havc particular utility in secondary arterial reconstructions. REFERENCES 1. Rich NM, Collins GJ Jr, Youkey JR, Salander JM, Donohue HJ, Elliott BM. Advcntitial cystic disease and entrapment syndromes involving the popliteal artery. In: Wilson SE, Vcith FJ, Hobson RW, Williams RA, eds. Vascular surgery: prin- ciples and practice. New York: McGraw-Hill Book Company, 1987: Shumacker HB lr. Incisions in surgery ofaneuusms. Ann Surg 1946;124: Szilagyi DE, Whitcomb JG, Smith RF. Anteromedial approach to the popliteal artery for femoropopliteal arterial grafting. Arch Surg 1959;78: Whittemore AD, Clowes AW, Couch NP, Mannick JA. Secondary femoropopliteal reconstruction. Ann Surg 1981; 193: Veith FJ, Gupta SK, Daly V. Management of early and late thrombosis of expanded polytetrafluoroethylene (PTFE) femoropopliteal bypass grafts: favorable prognosis with appropriate reoperation. Surgery 1980;87: Ascer E, Collier P, Gupta SK, Veith FJ. Reoperation for polytetrafluoroethylene bypass failure: the importance of distal outflow site and operative technique in determining outcome. J VASC SURG 1987;5: Henry AK. Extensile exposure, 2nd ed. New York: Churchill Livingstone, 1957: Elkin DC, Kelly RP. Arteriovenous aneurysm: exposure of the tibial and peroneal vessels by resection of the fibula. Ann Surg 1945;122: Danese CA, Singer A. Lateral approach to the popliteal artery trifurcation. Surgery 1968;63: