Chapter 37. Surgical Revascularization of Infrainguinal Arterial Occlusive Disease

• Disabling claudication.
• Critical limb ischemia, defined as rest pain or tissue loss.

Absolute

• Debilitated patient with severe comorbidities.
• Unaddressed inflow disease.
• Lack of an appropriate distal target for revascularization.

Relative

• Nondisabling claudication.
• Nonambulatory patient.
• Severe joint contractures.

• The patient should be supine with both arms extended; procedure-specific positioning is indicated later.
• A Foley catheter is inserted.
• A radial arterial line is placed.

• Doppler ultrasound signals should be checked frequently to monitor graft patency.
• Patients are maintained on a β-blocker, an antiplatelet agent, and a statin unless contraindicated.
• Antibiotics are stopped 24 hours after surgery unless there is an active infection (eg, an infected ulcer or toe).
• Epidural injection or patient-controlled analgesia may be used for postoperative pain management.
• Venous thromboembolic prophylaxis is started on postoperative day 1 using unfractionated heparin administered subcutaneously.
• Patients with significant edema and pedal wounds are treated with an Ace wrap and leg elevation.
• Sutures in the foot are removed only when the wounds are solidly healed, and not before 4 weeks.

• Local wound infections.
• Hematoma.
• Lymph leaks.
• Graft thrombosis.