In-Situ Saphenous Vein Graft for Lower Extremity Occlusive Disease

Bypass to infrageniculate arteries for chronic limb-threatening ischemia continues to provide a most challenging aspect of arterial reconstruction confronting vascular surgeons today. Their length and low flow all too often exceed the functional limits of synthetic and often even of reversed vein grafts. However, the saphenous vein used in situ provides a viable, physiologically active, and, hence, antithrombotic endothelial flow surface that is ideally suited for such bypasses. In addition, its gradual distal taper contributes an optimal hemodynamic configuration and a size match to the arteries it connects. These attributes have allowed consistent use of small veins that were previously considered unsuitable when used as reversed vein grafts, as reflected by higher vein utilization rates for bypass to the tibial arteries. Of equal or greater importance is the ability to use limited outflow tracts, such as isolated tibial segments, with no significant reduction in patency rates.

There is no question that this method of using the saphenous vein is on occasion tedious, time consuming, and demanding, but the surgeon’s patience and persistence are rewarded with immediate in-situ bypass function in more 95% of patients with the most diffuse and advanced stages of atherosclerotic occlusive disease. In selecting patients to be recipients of this investment of time and effort, one should be certain the indications for it are secure. Such operations for intermittent claudication are done infrequently with the full understanding by the patient that it is for functional improvement only, and can prejudice long-term limb preservation, because all reconstructions have a rate of attrition of approximately 5% a year. Once this vein is used electively, it is not available should limb-threatening degrees of ischemia develop in the future.