Patch-plasty of the popliteal artery (PA) is not always that easy. The artery is deep into the calf, muscle fibers surround it and even when all its run-off vessels have been dissected it is not always easy to put a Fogarty catheter into each one of them. Let me describe how I do it.
- Incision: the standard medial incision for the below-knee PA, on the upper end of calf. Just a bit longer than the usual. Start at a level of below the femoral tubercle, on the posterior edge of tibia, for a length of about 10-12 cm.
Dissection: dissect the subcutaneous tissue with the cautery down to the fascia. Cut the fascia (knife and scissors). Identify the gastrocnemius muscle and pull it down. Aim deep down, into the popliteal fossa, below the tibia. It is certain that the nervovascular bundle is there. The tibial nerve first, the vein back and the artery in the end. Pull the nerve anteriorly, dissect the popliteal vein and find the popliteal artery. Put a sling around and the first part is done.
- Finding the popliteal trifurcation: Identify the soles muscle, as it is attached on the posterior border of the tibia. Cut the muscle with a pair of scissors or the diathermy. Mind the small vein branches. Coagulate or double-ligate them. The aim now is the popliteal vein. You have found it, at a higher level together with popliteal artery. Dissect over it carefully and pull it slightly anteriorly. No you can identify the anterior tibial vein: just double ligate it and divide it. Now, the total vein can come anteriorly. After that the total length of the popliteal artery and the tibioperoneal trunk are just in front your eyes. Carefully dissect and put slings around the three branches: anterior tibial, posterior tibial and peroneal.
Arteriotomy and selective thrombectomy: this is the critical part. Make a long incision starting from the popliteal artery ending to the proximal part of the posterior tibial artery. It is important to be that long. Why? Because, this is the easiest way to make a proper embolectomy of each one of the run-off vessels with the least danger of making endothelial injury or dissection. This is because the orifices of the two of these run-off vessels (anterior tibial and peroneal) will be seen as two small holes on the opposite wall of the opened artery waiting there for a Fogarty catheter to get in. In this setup, the proximal inflow vessel is the popliteal artery and the distal outflow vessel is the posterior tibial artery.
Plasty: always use a venous patch. I prefer to use the best available vein which is the nearby long saphenous vein. I use a 6/0 polypropylene suture on a parachute technique. Easy peasy.
Extra technical tips: 1. Magnification (at least 2.5x), 2. Light like a sunny day (my preference is a head-light).