Reversed and Nonreversed Transposed Autogenous Vein Grafting for Atherosclerotic Lower Extremity Occlusive Disease

Patient Selection and Preoperative Evaluation

The quality of the conduit used is the single greatest factor in determining the outcome of lower extremity bypass grafts. Optimal planning requires knowledge of the location and quality of available vein. Infrainguinal bypass conduit is used preferentially in the following order: ipsilateral GSV, contralateral GSV, lesser saphenous or arm veins, composite (spliced) grafts, and nonautogenous grafts (biologic or synthetic). Up to 40% of patients do not have adequate ipsilateral GSV. Contralateral GSV should be considered next unless the donor limb also has evidence of advanced peripheral artery disease (PAD) by either clinical or hemodynamic assessment (e.g., ankle-to-brachial index [ABI] <0.5). Vein mapping with ultrasonography avoids unnecessary exploration of inadequate conduits, resulting in a more efficient operation and less wound morbidity. Adequate vein has a caliber of at least 3 mm and does not harbor noncompressible or thrombosed segments. However, marginal segments are not reliably identified on preprocedure imaging, and the best tool to assess vein quality is intraoperative inspection. If sclerotic or nondistensible segments are encountered, it is far better to excise the segment and splice two healthy ends of vein rather than retain a marginal segment that could increase the likelihood of graft failure.

In cases where sufficient vein of adequate quality is in short supply, a variety of techniques can help minimize the length of vein needed. A patch angioplasty can move the proximal or distal anastomosis by several centimeters. Tunneling anatomically minimizes the length of vein needed. Excellent outcomes can also be achieved with grafts originating beyond the common femoral artery. Hybrid endovascular and open surgical techniques can be employed in carefully selected cases to move the site of inflow distally. For example, endovascular treatment of mild to moderate superficial femoral artery (SFA) disease followed by a distal-origin graft from the popliteal artery can reduce the length of vein needed by half. However, endovascular treatment of more severe femoropopliteal disease (e.g., Trans-Atlantic Inter-Society Consensus [TASC] C or D lesions) upstream of a bypass is to be discouraged as a strategy, because a good-quality venous conduit generally outlasts such extensive endoluminal SFA interventions.