Aortofemoral Bypass

Anesthesia Implications

Position: Supine, arms extended
Time: 2-4 hours (long)
Blood Loss: Moderate (50 – 200 ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: Yes

Multiple Comorbidities – Anticipate that these patients will have multiple comorbidities. Common to this group are peripheral vascular disease, diabetes, renal disease, and coronary artery disease.

Central Line – A central line is sometimes needed depending on the patient’s condition.

A-line – needed for the multiple ACTs taken during the procedure as well as hemodynamic changes (common as the surgeon clamps and unclamps the aorta).

Epidural – an epidural MAY be indicated. Epidurals significantly cut down on postoperative pain/narcotics and may be continued for days after the surgery. Communicate with the surgeon to establish the best plan.

Aortic Clamps – There’s usually some lability in blood pressures (which can be drastic) after the aorta is clamped/unclamped. Great to have a Nitroglycerine push available and a Neosynepherine/levophed drip.

Heparin and Protamine – Heparin will be given intraoperatively. Protamine will also likely be given at the end of the case. Communicate with surgeon about the dosage and timing of both of these drugs.

Coughing / Increased Abdominal Pressure – where not contraindicated, consider a deep extubation to avoid coughing. Give thorough PONV prophylaxis.

Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.

Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.

High blood loss RISK (general considerations): Though most of these cases don’t result in a high blood loss, there is a high blood loss RISK. Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra IV push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.

Bypass blocked or narrowed femoral arteries by attaching an artificial graft from the ascending aorta to more patent femoral arteries distal to the blockage.

This surgery can be done either open or endovascularly by stenting.

These patients typically have many co-morbidities, such as: PVD, CAD, DM, HTN, and renal disease. Neuropathy is also common in these patients.