Consent: Axillofemoral Bypass

This article is for educational purposes only. It should not be used as a template for consenting patients. The person obtaining consent should have clear knowledge of the procedure and the potential risks and complications. Always refer to your local or national guidelines, and the applicable and appropriate law in your jurisdiction governing patient consent.

Overview of Procedure

A axillo-bifemoral/femoral bypass is typically undertaken when there is significant aortic occlusion or bilateral iliac occlusion in a patient not fit or suitable for aortic surgery.

It involves dissection of the axillary artery as well as the common femoral arteries. These are slung and clamped where the artery becomes healthy again, with the artery opened longitudinally and a graft, tunnelled superficially between the incision, is anastomosed.

Fig 1 – Axillofemoral bypass. (A) Preoperative CT showing marked irregular narrowing of the descending thoracic and abdominal aorta. (B) Postoperative CT showing a patent axillofemoral bypass graft.

Complications

Intraoperative

Complication Description of Complication Potential Ways to Reduce Risk
Haemorrhage This can occur due to damage to either the artery or the femoral vein or its branches, and may require blood transfusion(s).
Injury to surrounding structures including The femoral artery lies between the femoral nerve and femoral vein. Either of these can be damaged during the dissection if not careful. Likewise the axillary vein can be damaged during axillary artery dissection. Dissect using a standard approach with identification of the inguinal ligament primarily, then approach the artery proximally
Anaesthetic risks Includes damage to the teeth, throat and larynx, reaction to medications, nausea and vomiting, cardiovascular and respiratory complications. Forms a part of the anaesthetist assessment before the operation

Early

Complication Description of Complication Potential Ways to Reduce Risk
Pain The patient will most likely have an epidural anaesthetic to minimise this or use of local anaesthesia during the procedure.
Bleeding There is a small chance of bleeding and bruising in the groin or axilla post-operatively.
Infection Superficial wound infection is possible, most common in the groin. A graft or patch infection if occurs is a major complication requiring life-long antibiotics. Peri-operative antibiotics will reduce the risk of wound and graft infections
Scarring A longitudinal or transverse incisions will result in a scar, which may form a keloid scar, particular in high risk ethnicities.
Seroma A swelling of lymphatic fluid may occur particularly in the groin due to disruption of the lymph nodes and channels. Careful dissection of the lymphatic nodes and channels with ligation will minimise this risk.
Blood clots DVTs and PEs are a possibility in any operation. The risk is increased in patients with a raised BMI, on the pill, recent flights, previous DVT, pregnancy, smokers, cancer and prolonged bed rest. The patient will be given anti-embolism stocking and low molecular weight heparin to minimise this risk as deemed appropriate.
Compartment syndrome Compartment syndrome may occur in patients with prolonged clamp times or in the acute setting. Patients with a long history of peripheral vascular disease are preconditioned for ischaemia so it is less likely. Minimise clamp times
Stroke, MI, kidney failure, death Although small, this is always a risk in any major surgery

Late

Complication Description of Complication Potential Ways to Reduce Risk
Hernia Any groin incision can cause a hernia if there is damage to the inguinal ligament or extensive lifting of the ligament during the procedure.
Reintervention The common femoral artery may become stenosed again over time, requiring a redo procedure, or more proximal or distal disease may necessitate a bypass in the future. The graft can also fail over time.

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