Open repair (gold standard)

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**Open repair (bypass with aneurysm exclusion)**

**Technique (common approach)**

- Proximal and distal control with **ligation/exclusion** of the aneurysm.
- Bypass from superficial**superficial femoral artery (SFA)** to distal popliteal (or tibial target when needed) with:

  - **Autologous vein** preferred (reversed or in situ great**great saphenous vein).vein (GSV)**). [@esc2017] [@rutherford2018-rutherford]
  - Prosthetic**Prosthetic conduitconduit** reserved for selected patients when vein is unavailable, generally with inferior durability in below-knee targets. [@rutherford2018-rutherford]

**Approach selection (practical)**

- **Medial approach** facilitates longer bypasses and tibial targets when distal embolization/runoff disease is present. [@rutherford2018-rutherford]
- **Posterior approach** may be used for selected aneurysms confined to the popliteal fossa where direct aneurysm handling is required (for example, compressive symptoms), but is less flexible for tibial targets. [@rutherford2018-rutherford]

**Outcomes and durability**

- In elective settings with good conduit and runoff, open repair provides durable long-term patency and limb salvage, historically in the **70-90% 5-year** range in surgical series. [@galland2008]
- Presentation matters: acute thrombosis/embolization and poor runoff are associated with worse patency and higher reintervention risk. [@esc2017] [@rutherford2018-rutherford]
- **Socioeconomic status (SES)** also significantly impacts outcomes following revascularization for atherosclerotic **peripheral arterial disease (PAD)** and aneurysm repair, with lower SES associated with increased risks of adverse events and limb loss. [@zileali2024]

**Antithrombotic therapy and risk reduction**

- Long-term **single antiplatelet therapy** and statin therapy are generally recommended for atherosclerotic peripheral arterial disease (PAD)PAD risk reduction after infrainguinal bypass. [@ahaacc2016] [@hps2002]
- Consideration of intensified antithrombotic strategies should be individualized based on bleeding risk and the type of reconstruction (see [[Lower Extremity Arterial Occlusive Disease|Ch. 10]]). [@eikelboom2017] [@voyager2020]

**Postoperative surveillance**

- Structured duplex surveillance improves detection of clinically significant graft stenosis and supports secondary patency. [@almasri2018] [@esc2017]