Femorofemoral (Femoral-Femoral) Bypass

Updated: Jun 02, 2020
  • Author: Cheong Jun Lee, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
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Femorofemoral (femoral-femoral) bypass is a method of surgical revascularization used in the setting of unilateral common and/or external iliac artery occlusive disease. The technique is dependent upon a patent iliac arterial system without hemodynamically significant disease to supply adequate inflow of blood to both lower extremities. It is a commonly used means of extra-anatomic vascular reconstruction for patients with disabling claudication or critical limb-threatening ischemia (CLTI) in whom underlying anatomic constraints rule out endovascular means of restoring in-line flow and those who do not qualify for anatomic reconstruction because of comorbidities that preclude a more invasive open approach.

Femorofemoral bypass may also be used as a component of endovascular repair of abdominal aortic aneurysms (AAAs), [1] whereupon one aortoiliac system is occluded on an emergency or elective basis to ensure exclusion of the aortic aneurysm. Primary patency rates of femorofemoral bypasses are estimated to be in the range of 65-70% at 5 years. [2, 3, 4]  The bypass patency rates, however, are inferior to in-line reconstruction benchmarks set by the aortofemoral and iliofemoral bypass operations.



Indications for femorofemoral bypass are as follows:

  • Symptomatic lower-extremity ischemia (disabling claudication, rest pain, tissue loss) due to acute or chronic occlusion of a unilateral iliac artery system
  • Adjunct to an endovascular unilateral aortoiliac exclusion of an AAA
  • Unavailability of endovascular options for management of iliac occlusive disease
  • High-risk patients with significant comorbidities (cardiopulmonary, multiple prior abdominal operations, prior radiation therapy to the abdomen, abdominal stoma) that preclude in-line reconstruction with inflow from the proximal iliac artery or the aorta

In a retrospective study of 82 consecutive patients with CLTI from unilateral iliofemoral artery occlusion, Ma et al found that femorofemoral bypass to the deep femoral artery appeared to be safe, durable, and effective for limb salvage after attempted percutaneous endovascular intervention had failed. [5]

Femorofemoral bypass has also been used, in conjunction with retrograde endovascular aortoiliac intervention, as a component of a hybrid approach to bilateral lower-extremity inflow revascularization. [6]



Contraindications for femorofemoral bypass are as follows:

  • Compromised inflow aortoiliac arterial segment
  • Significant obesity that may cause unfavorable graft geometry
  • Extreme medical risks for surgery

Technical Considerations

Complication prevention

The inflow aortoiliac arterial system must be thoroughly preoperatively assessed. The outflow common, superficial, or deep femoral artery must be thoroughly assessed as well.

Strict attention to sterile technique should be used when handling prosthetic grafts. A wide sterile field is necessary to manage intraoperative bleeding or other unexpected complications that can arise while performing the procedure.

The geometry of the graft tunneling should be carefully assessed; the graft should be in an inverted C (or gentle S) configuration to prevent undue tension and kinking at the anastomoses.