Bypass graft to the midpopliteal artery with a combined anterior and posterior approach

Purpose: The medial supragenicular and infragenicular approaches to the pop liteal artery were introduced almost 50 years ago and replaced the posterio r approach to the popliteal artery for distal graft implantation. We review a contemporary series of bypass grafts to the midpopliteal artery by use o f a combined anterior and posterior approach to evaluate its potential clin ical benefits. Technique: After the proximal graft anastomosis is constructed, an incision is made in the popliteal fossa to access the midpopliteal artery, the graf t is passed into that incision, and all but the popliteal incision is close d. The patient is turned, the midpopliteal artery dissection is completed, and the graft is anastomosed distally. Methods: Fifty-seven bypass grafts, implanted distally on the midpopliteal artery by this technique over a 13-year period, chosen in preference to an infragenicular bypass graft in selected patients when a supragenicular bypa ss was not feasible, were assessed in terms of indications for surgery, con duit type, complications, length of postoperative hospitalization, and graf t patency. Results: Bypass grafting originated from the axillary artery in two cases, the common iliac artery in one case, and the femoral artery in 54 cases. Th e procedure was performed in five patients with a popliteal trifurcation an omaly, nine patients with a blind popliteal segment, 20 patients with limit ed length of autologous vein, and five patients with an above-knee graft in fection requiring an alternate path for revascularization. Autologous vein was used in 35 and polytetrafluoroethylene (PTFE) in 19 bypass grafts. Thre e other patients had a composite sequential femoral-popliteal-tibial bypass graft, with PTFE and autologous vein. Postoperative (30 day) complications include one death (composite sequential), one stroke (PTFE), and one graft thrombosis (saphenous vein). The mean postoperative hospitalization for th e last 31 patients was 4.2 +/- 3.7 days. In the autologous vein group, the 1-year primary patency rate was 87%, and the primary assisted patency rate was 94%. In the PTFE group, the 1-year primary patency rate was 72%. Two co mposite sequential grafts remained patent at 1 year. Conclusions: Bypass grafting to the midpopliteal artery with a combined ant erior and posterior approach offers a safe and effective option to below-kn ee bypass grafting when an above-knee bypass grafting is not feasible. Comp ared with the medial infragenicular incision, the posterior incision result s in reduced morbidity rates, rapid mobilization, and early hospital discha rge.