Guideline‑Concordant Redo Aorto‑Bifemoral Bypass with Bilateral Profunda Femoris Reimplantation and Epiploplasty for Critical Limb‑Threatening Ischaemia

Background: Redo aortoiliac and femoral revascularisation in patients with multiple prior interventions is technically demanding and associated with increased perioperative risk. Current European Society of Cardiology 2024 Guidelines (ESC 2024) and Global Vascular Guidelines 2019 (GVG 2019) emphasise preservation or reconstruction of the profunda femoris arteries, minimisation of dissection in hostile operative fields, and use of adjunctive measures to reduce infection risk. Case presentation: We report the case of a 67‑year‑old man with severe peripheral arterial occlusive disease and a history of right iliac stenting, left‑to‑right femoro‑femoral crossover bypass, and aorto‑bi‑iliac bypass. He presented with bilateral critical limb‑threatening ischaemia (CLTI) with an ankle–brachial index (ABI) of 0.30 due to thrombosis of both grafts. Surgical management consisted of an infrarenal aorto‑bifemoral bypass using an 18 mm Dacron graft with distal anastomoses to the superficial femoral arteries (SFA), bilateral profunda femoris artery reimplantation using 6 cm autologous great saphenous vein grafts, and protective epiploplasty. Intraoperative infrarenal clamp time was 20 minutes. The immediate postoperative course was uneventful, with restoration of femoral and popliteal pulses and resolution of ischaemic pain. Discussion: This anatomy‑driven, guideline‑concordant approach avoided hostile scarred groins, preserved deep collateral circulation, and incorporated infection‑prevention measures. One‑year follow‑up with duplex ultrasonography and computed tomography angiography (CTA) confirmed primary graft patency, absence of recurrent ischaemia, and full functional recovery. The case aligns with published evidence supporting profunda preservation in complex redo surgery and illustrates the feasibility of durable revascularisation in multiply operated patients. Conclusion: In complex redo aortoiliac and femoral reconstructions, strategic anatomical planning, profunda femori