The lesser saphenous vein: an underappreciated source of autogenous vein.

Use of the ipsilateral greater saphenous vein for arterial bypass procedures is frequently limited by previous stripping, bypass operations, or anatomic unsuitability. In such cases the contralateral greater saphenous vein or arm veins are often used. However, over the past 5 years we have used the lesser saphenous vein as a preferred alternative autogenous vein. Duplex scanning has been used in 311 cases for preoperative mapping and assessment with excellent correlation with actual anatomy found at operation. Harvest of the lesser saphenous vein has been facilitated by the use of a medial subfascial approach not requiring special positioning of the leg. A total of 91 lesser saphenous veins have been used for arterial bypass procedures; 66 of these were repeat cases. Vein use was 90.2%. In 40 of these cases the lesser saphenous vein was used as the entire conduit, including 10 in situ, 20 reversed vein (including 18 for coronary artery bypass), and 10 orthograde vein bypasses. In the remaining 33 cases the lesser saphenous vein was spliced to another vein to complete a bypass procedure. In the entire group, patency was 77% at 2 years. These data suggest that the lesser saphenous vein should be a principal alternative to ipsilateral greater saphenous vein for arterial bypass because of its ready availability, high use rate, ease of harvesting and preparation, and ideal handling characteristics.     

Present status of reversed vein bypass grafting: five-year results of a modern series

From January 1980 through December 1988, 564 limbs in 434 patients were treated for infrainguinal arterial ischemia. Of these, 516 limbs in 387 patients underwent reversed vein bypass grafting. The remainder were treated by primary amputation (11 limbs, 1.9%) or by prosthetic bypass (37 limbs, 6.4%). The indications for operation were limb salvage in 80% of limbs and claudication in 20%. Adequate ipsilateral greater saphenous vein was available for 285 (55%) grafts, with reversed vein bypass achieved in the other 231 operations by use of distal graft origins (151 grafts), use of alternate vein sources (120 grafts), and splicing of venous segments (81 grafts). Seventy-six grafts (15%) were to the above-knee popliteal artery, 199 grafts (37%) were to the below-knee popliteal artery, and 241 grafts (47%) were to infrapopliteal arteries, 26 of which (11%) were to inframalleolar arteries. The primary and secondary patencies for all grafts at 5 years were 75% and 81%, respectively. Grafts to infrapopliteal arteries had significantly worse primary patency (69%) at 5 years than did grafts to the popliteal artery (77%, above knee; 80%, below knee) and grafts formed of adequate ipsilateral greater saphenous vein had significantly better primary patency (80%) than did grafts performed when this conduit was not available (68%). Secondary patency of all graft categories ranged from 76% to 85%, and there were no significant differences regardless of site of distal anastomosis, source of venous conduit, or site of graft origins. We prefer the use of reversed vein bypass grafting for lower extremity revascularization both because of the excellent patency results and because the technique can be applied to the larger number of patients in our practice who lack intact ipsilateral greater saphenous vein, in contrast to in situ vein bypass procedures.     

Non-greater saphenous vein grafting for infrageniculate bypass

Infrainguinal bypass grafting with greater saphenous vein has proven to be a highly effective procedure with primary 5-year patency and limb salvage rates exceeding 80 per cent. However, because of prior usage or intrinsic venous disease the greater saphenous vein is often not available as a conduit. Numerous studies have shown that patency rates for prosthetic bypass grafting to the infrageniculate vessels are clearly inferior to that reported for greater saphenous vein bypass. In this report we summarize our experience with the use of alternate autogenous vein grafting to the infrageniculate vessels. The records of all patients undergoing autogenous bypass grafting to the infrageniculate vessels using a conduit other than the greater saphenous vein between 1992 and 1999 were reviewed. Graft survival curves were plotted using the Kaplan-Meier method and results are reported using the Society for Vascular Surgery/International Society for Cardiovascular Surgery guidelines. Forty-eight patients underwent a total of 51 infrageniculate bypass procedures using non-greater saphenous autogenous conduits. Thirty-nine patients had reconstructions performed with single segments of arm vein, two had their operations performed with lesser saphenous vein, and ten had grafts created with two segments of non-greater saphenous autogenous vein. Twenty-one grafts were performed to the infrageniculate popliteal artery and 30 were performed to the tibial vessels. Primary and primary assisted patency rates at 30 months were 49 and 75 per cent. Limb salvage was 87 per cent. Infrainguinal bypass grafting using non-greater saphenous autogenous conduits can yield quite satisfactory intermediate limb salvage and patency rates. However, close graft surveillance and prompt intervention are required to avoid graft failure.     

Technical modifications in endoscopic vein harvest techniques facilitate their use in lower extremity limb salvage procedures

OBJECTIVE: We describe and report our results using endoscopic vein harvest (EVH) for lower extremity arterial bypass procedures, following the implementation of technical modifications specific to patients undergoing limb salvage procedures. METHODS: We underwent training in EVH, followed by implementation of the technique in patients requiring limb salvage for lower extremity ischemia and aneurysms. After technical modifications in the technique were developed for limb salvage, we reviewed our experience in all patients who underwent minimally invasive distal bypass with EVH. RESULTS: Technical modifications include limited arterial dissection before vein harvest, the use of proximal and distal leg incisions for both exposure of arterial vessels and saphenous vein harvest, improved hemostasis techniques in the vein graft tunnel, avoidance of compression wraps to the ipsilateral harvest tunnel, complete removal of the vein with either reversed or nonreversed graft placement, and use of the endoscopic tunnel for conduit placement. Thirteen patients (14 limbs) have undergone minimally invasive distal bypass since technical modifications were implemented. Indications for EVH were rest pain (n = 12; 85.7%) and tissue loss (n = 8; 57.1%). Veins harvested were the ipsilateral great saphenous vein (n = 10; 71.4%), contralateral great saphenous vein (n = 2; 14.3%), and short saphenous vein (n = 2; 14.3%). No venous injuries occurred during endoscopic harvest, and all were used for bypass. Thirty-day primary and primary assisted patency rates were 85.7% and 92.9%, respectively. The limb salvage rate was 100%. Two patients developed postoperative hematomas, one early and one late, as a result of anticoagulation for cardiac comorbidities. Both patients required reoperation for successful re-establishment of patency. There were no perioperative deaths and no postoperative wound infections or complications. Two patients required a later prosthetic bypass, and two required a vein graft angioplasty. Complete wound healing was achieved in 75% of patients with preoperative tissue loss. CONCLUSIONS: Technical modifications in endoscopic saphenous vein harvest techniques facilitate their use in lower extremity limb salvage procedures. Vascular surgeons should become familiar with these techniques to minimize vein harvest wound complications and extend the options for limb salvage conduits, including use of both the ipsilateral and contralateral saphenous vein and the short saphenous vein. Meticulous hemostasis within the tunnel after endoscopic conduit harvest and avoidance of postoperative anticoagulation should help to prevent postoperative hematoma formation and early graft occlusion.     

Extra-anatomic bypass graft for management of axillary artery occlusion in pitchers

OBJECTIVE: Our goal was to evaluate the long-term results of vein bypass grafts for axillary artery occlusion, specifically those placed extra-anatomically to prevent arterial injury in pitchers. METHODS: With the greater saphenous veins used as the selected conduit, arterial bypass grafts were routed anterior to the pectoralis minor muscle in four baseball pitchers who had occlusion of the axillary artery. We performed a follow-up in excess of 10 years with evaluations of the bypass grafts by ultrasonic duplex scan and magnetic resonance angiography. RESULTS: All four pitchers treated in this manner returned to the game and played for several seasons without a recurrence of the arterial injury. Long-term evaluation of the bypass grafts did not reveal any structural or functional disorder. CONCLUSIONS: Axillary artery occlusion in an athlete can be effectively treated with a vein bypass graft placed extra-anatomically, anterior to the pectoralis minor muscle. The greater saphenous vein should be considered the conduit of choice.     

Comparison of the flow capacity of free arterial grafts and saphenous vein grafts for coronary bypass surgery

There is controversy regarding the flow reserve and capacity of arterial conduits to meet the needs of the myocardium. This study compared flow in 22 free arterial bypasses to 15 saphenous vein grafts in procedures involving twenty patients. To assess the maximal flow possible, (flow capacity) graft flow was measured using a calibrated pump while perfusing blood cardioplegia through the conduit and distal anastomosis during cardiac arrest (no competitive flow). This assessment was subsequently confirmed with whole blood during myocardial contraction while on cardiopulmonary bypass. Twenty-two free arterial grafts were used; 15 right internal mammary artery grafts, 4 right gastroepiploic grafts, 3 inferior epigastric artery grafts, and 3 sequential bypasses. Free arterial conduit flow ranged from 50 to 180cc/ml, with an average flow of 102.5+/-28.5ml/min as compared to saphenous vein graft flow, 102+/-28 ml/min. No correlation of flow with the conduit size was found. Arterial graft flow demonstrated a mild correlation with the size of the native coronary artery bypassed (R=0.47, P相似文献   

Small arterial reconstruction using modified cadaveric saphenous veins

Human saphenous veins removed from cadaver donors were subjected to proteolytic enzymatic digestion, cross bonding, and heparin bonding. They were tested as small arterial substitutes in dogs. Eight of eleven were successful, persisting without development of stenosis or aneurysm, the longest for eighteen months. In humans, similarly prepared veins were used as arterial bypasses to revascularize ischemic limbs in eleven patients and aneurysmal degeneration of an earlier unmodified allograft bypass in one patient. Distal arterial anastomoses were to the tibial and peroneal arteries. Nine patients who had not undergone previous reconstructive surgery involving the vessel used for distal anastomosis were treated successfully; all remain with healed limbs between three and twelve months after surgery, eight with functioning bypasses. In three patients who had undergone previous operations on the same artery used for distal anastomosis, long bypasses failed, although amputation was avoided in one patient by additional bypass with modified vein to the profunda femoris artery. We conclude that modified saphenous vein allografts are suitable small arterial substitutes. It remains to be seen whether veins will maintain patency for long periods without development of complications.     

Bypass to plantar and tarsal arteries: an acceptable approach to limb salvage

OBJECTIVE: This study was undertaken to evaluate our experience with distal arterial bypass to the plantar artery branches and the lateral tarsal artery for ischemic limb salvage. METHODS: This was a retrospective analysis of data prospectively entered into our vascular surgery database from January 1990 to January 2003 for all consecutive patients undergoing bypass grafting to the plantar artery branches or the lateral tarsal artery. Median follow-up was 9 months (range, 1-112 months). Demographic data, indications for surgery, outcomes, and patency were recorded, and statistical analysis was performed to assess significance. RESULTS: Ninety-eight bypass procedures to either the medial plantar artery, lateral plantar artery, or lateral tarsal artery were performed in 90 patients. Eighty-one patients (83%) were men. Mean age was 67.5 +/- 11.6 years. Indications for operation were tissue loss in 93 patients (95%), rest pain in 3 patients (3%), and failing graft in 2 patients (2%). Eighteen patients (18%) had previously undergone vascular reconstruction, and 5 patients (5%) had undergone previous bypass to the dorsalis pedis artery. Seventy-one grafts (72%) had inflow from the popliteal artery, 25 grafts had inflow from a femoral artery or graft (26%), and 2 grafts had inflow from a tibial artery (2%). Conduits used were greater saphenous vein in 67 patients (69%), arm vein in 20 patients (20%), composite vein in 10 patients (10%), and polytetrafluoroethylene conduit in 1 patient (1%). There were 77 bypasses (79%) to plantar artery branches, and 21 bypasses (21%) to the lateral tarsal artery. Thirty-day mortality was 1% (1 of 98 procedures). Early graft failure within 30 days occurred in 11 patients (11%). In the subset of patients with a previous arterial reconstruction, there were 2 early graft failures within 30 days (11%). Both occurred in patients who had undergone previous bypass to the dorsalis pedis artery. Primary patency, secondary patency, limb salvage, and patient survival were 67%, 70%, 75%, and 91%, respectively, at 12 months, and 41%, 50%, 69%, and 63%, respectively, at 5 years, as determined from Kaplan-Meier survival curves. Greater saphenous vein grafts performed better than all other conduits, with a secondary patency rate of 82% versus 47% at 1 year (P = .009). CONCLUSION: Inframalleolar bypass to plantar artery branches and the lateral tarsal artery, even in patients with a previously failed revascularization, can be undertaken with acceptable patency and limb salvage rates. Early graft failure, however, is higher, whereas patency and limb salvage rates are lower, compared with bypass to the dorsalis pedis artery. The use of saphenous vein as a conduit results in the best patency for plantar or lateral tarsal bypass procedures.     

A simple means of access for harvesting the lesser saphenous vein

Enhanced patient expectations combined with improvements in vascular technique have increased the number of lower limb arterial bypass operations performed. The natural consequence is a parallel increase in the number of re-operations for failed or failing bypasses where the optimal conduit--the ipsilateral long saphenous vein has already been used. Indeed, there are many occasions where the long saphenous vein cannot be utilised at the primary operation, either because of the demands of coronary artery bypass surgery, or because of the presence of phlebitic vein segments. As autologous vein is generally preferred to prosthetic material for distal (tibial) bypasses, the vein must be harvested from other sites. Frequently there is insufficient or inadequate arm vein from a single source. Also, there is a natural reluctance to use the contralateral long saphenous vein, even if it is still available, because of the potential need for an arterial bypass on that side. The short saphenous vein is a valuable alternative. We describe a simplified approach (compared to the more conventional posterior approach) to harvest this vein which can then be used either in isolation or in combination with a superficial femoral endarterectomy or as part of a composite vein graft.     

Minimally invasive axillary-LAD saphenous vein bypass

The left internal mammary artery (LIMA) is the arterial conduit of choice for minimally invasive coronary bypass to the left anterior descending (LAD). However, in redo cases when the LIMA is not available, the use of a saphenous vein graft as an extra-anatomic bypass from the axillary artery to the LAD offers a lower risk alternative than conventional reoperative trans-sternal surgery [Knight 1997]. We report on 3 patients who underwent axillary-LAD saphenous vein bypass. At six months, follow-up by Duplex ultrasound showed patent grafts in all three patients.     

Distal venous patch improves results in PFTE bypasses to tibial arteries

In recent years, the management of limb-threatening ischemia has involved the use of distal bypasses to vessels beyond the popliteal trifurcation. Excellent patency rates and limb salvage data are achieved through the use of autologous long saphenous vein. However, an increasing number of patients in need of tibial bypass do not have adequate saphenous vein due to previous procedures, thrombophlebitis, or inadequate vein. In such cases alternative conduits have been proposed including lesser saphenous vein, arm vein, composite veins, composite vein with polytetrafluoroethylene (PTFE), and PTFE with or without a distal arteriovenous fistula. Unfortunately these alternative conduits have not resulted in equivalent results when used for distal bypass to tibial arteries. Several authors have reported upon the use of venous tissue at the distal anastomosis in the form of cuffs, collars, and boots to improve the results of prosthetic grafts in this challenging patient population. These techniques have been proposed as an option for revascularization in patients without adequate saphenous vein in an attempt to obtain limb salvage. The purpose of this review is to examine some of those techniques and focus on distal vein patch configuration with its perceived advantages and drawbacks.     

Distal Venous Patch improves results in PFTE bypasses to Tibial arteries

In recent years, the management of limb-threatening ischemia has involved the use of distal bypasses to vessels beyond the popliteal trifurcation. Excellent patency rates and limb salvage data are achieved through the use of autologous long saphenous vein. However, an increasing number of patients in need of tibial bypass do not have adequate saphenous vein due to previous procedures, thrombophlebitis, or inadequate vein. In such cases alternative conduits have been proposed including lesser saphenous vein, arm vein, composite veins, composite vein with poly-tetrafluoroethylene (PTFE), and PTFE with or without a distal arteriovenous fistula. Unfortunately these alternative conduits have not resulted in equivalent results when used for distal bypass to tibial arteries. Several authors have reported upon the use of venous tissue at the distal anastomosis in the form of cuffs, collars, and boots to improve the results of prosthetic grafts in this challenging patient population. These techniques have been proposed as an option for revascu-larization in patients without adequate saphenous vein in an attempt to obtain limb salvage. The purpose of this review is to examine some of those techniques and focus on distal vein patch configuration with its perceived advantages and drawbacks.     

Radial artery as conduit for distal renal artery reconstruction

Reconstruction of the renal artery with both saphenous vein and prosthetic material as bypass graft is durable in atherosclerotic disease. Extensive experience with saphenous vein grafts in pediatric patients and patients without atherosclerosis reveals a disturbing incidence of vein graft aneurysm degeneration. Distal renal artery reconstruction involving small branch vessels is generally not amenable to prosthetic reconstruction. We report a new approach to distal renal artery bypass grafting to avert these limitations. CASE: A 43-year-old man with previously normal blood pressure had malignant hypertension, which proved difficult to control despite use of a beta-blocker and an angiotensin II inhibitor. At renal angiography a fusiform aneurysm was revealed in a posterior branch of the right renal artery. The renal artery aneurysm was resected, and the left radial artery was harvested and used as a sequential aortorenal bypass graft to the two branch renal arteries. The postoperative course was uneventful, and the patient now has normal blood pressure with a calcium channel blocker for maintenance of the radial artery graft. Pathologic analysis revealed a pseudoaneurysm with dissection between the media and external lamella, consistent with fibromuscular dysplasia. CONCLUSION: Autologous artery is the preferred conduit for renal reconstruction in the pediatric population. On the basis of cardiac surgery experience, we used the radial artery and found it to be a technically satisfactory conduit for distal renal reconstruction in a patient without atherosclerosis.     

股腘动脉闭塞症的手术治疗

目的 探讨股腘动脉旁路移植术治疗下肢动脉硬化闭塞症(C、D级病变)的近中期疗效.方法 2005年1月至2009年2月,170例患者(191条肢体)行股动脉以远血管重建术.其中男性108例,女性62例;年龄45～85岁,平均67岁.症状包括间歇性跛行78例,静息痛62例,下肢缺血性溃疡19例,远端组织坏死11例.所有患者术前均行动脉造影检查,根据TASC Ⅱ分级:C级病变127条肢体,D级病变64条肢体.手术方法包括大隐静脉原位旁路移植术15条肢体,大隐静脉转位20条肢体,人工血管旁路移植术128条肢体,大隐静脉与人工血管组合旁路移植术28条肢体.结果 围手术期无死亡病例.术后随访6～36个月,平均(24±6)个月;76例失访,随访率57%(109/191).一期通畅率84.4%(92/109),其中人工血管旁路移植通畅率88.2%(75/85),大隐静脉(原位、转位、组合)旁路移植通畅率70.8%(17/24).二期通畅率89.9%(98/109).结论 人工血管旁路移植术是治疗严重股腘动脉闭塞症(TASC C和D级病变)的主要方法,手术疗效满意.     

Creation of spliced vein conduit using microvascular anastomotic coupler

The single-segment great saphenous vein continues to be a conduit of choice for lower extremity arterial bypass. In patients without an adequate continuous segment of great saphenous vein, a spliced vein graft may be used as an alternative. Creating a spliced vein conduit can be technically challenging and time consuming. We present a technique of creating a spliced vein conduit by using a microvascular anastomotic coupler.     

Cryopreserved saphenous vein allografts for below-knee lower extremity revascularization.

OBJECTIVE: Cryopreserved saphenous vein allografts have been offered as an alternative conduit for bypass in ischemic limbs. The authors examined the efficacy of this conduit for arterial bypass to the distal popliteal and tibial arteries in patients in whom autogenous vein was not available. SUMMARY BACKGROUND DATA: Previous experience with arterial and venous allografts has been unsatisfactory because of aneurysmal degeneration and poor patency. Endothelial loss and host rejection have been suggested as mechanisms of graft failure. Cryopreservation by modern techniques with rate controlled freezing, dimethyl sulfoxide (DMSO), and other cryopreservants, has addressed these issues and rekindled interest in vein allografts. METHODS: Over a period of more than 5 years, 115 cryopreserved vein allografts were implanted in 87 limbs to the distal popliteal (14) or tibial (101) arteries. The indication for surgery was rest pain in 56 procedures (49%), gangrene in 36 (31%), claudication in 21 (18%), and replacement of aneurysmal allografts in 2. Follow-up was 1 to 61 months (mean 25 months). RESULTS: There was no significant difference in patency related to site of proximal or distal anastomosis, patency of runoff vessels, use of anticoagulation, age, sex, diabetes, hypertension, smoking, indication, source of graft, or use of multiple segments. Revision was required in six grafts for aneurysmal dilatation. Histologic examination of explanted sections of allografts showed no immune response, and immunosuppressive drugs were not used. CONCLUSIONS: Although limb salvage has been satisfactory, long-term patency rates for cryopreserved vein allografts are poor when compared with autogenous vein. The cost of cryopreserved allografts far exceeds that of prosthetic grafts, for which comparable and superior results have been reported. Use of cryopreserved vein allografts should be reserved for situations in which adequate lengths of autogenous vein do not exist and the risk of infection of prosthetic grafts is high.     

Outcomes of combined superficial femoral endovascular revascularization and popliteal to distal bypass for patients with tissue loss

Over the last 5 years there has been a significant shift toward lower limb revascularization using endoluminal techniques. However, in many instances endoluminal techniques alone are unable to salvage limbs that exhibit tissue loss. Many of these patients do not have adequate conduit for a long leg bypass, while tibial angioplasty does not appear to restore adequate perfusion to heal many significant foot lesions, making combined procedures attractive. However, previously available data evaluating combined endoluminal and bypass procedures have been too anatomically heterogeneous to be easily applied to patients with infrainguinal disease and tissue loss. From January 2002 to December 2005, intraoperative superficial femoral artery (SFA) percutaneous transluminal angioplasty (PTA) with selective stenting combined with simultaneous popliteal to distal vein bypass was evaluated in 22 limbs of 22 patients with isolated infrainguinal disease and tissue loss. There were 12 men and 10 women, average age 69. All the patients were diabetic, all had tissue loss, and three had end-stage renal disease (ESRD). Four patients underwent common femoral endarterectomy at the time of the SFA PTA; all had the PTA performed first, with antegrade punctures and flow maintained. Fourteen patients had PTA without stenting, eight had self-expanding stents placed for residual stenosis or dissection. There were no failures, with three TASC A, 13 TASC B, and six TASC C lesions addressed. The origin of the bypass was the above-knee popliteal in eight patients and the below-knee popliteal in 14 patients. The target vessel was the dorsalis pedis in six patients, the posterior tibial at the malleolus in three, the proximal posterior tibial in five, the peroneal in five, and the anterior tibial in three. The conduit was greater saphenous vein in 16 cases, femoral vein in three cases, and arm vein in three cases. Follow-up ranged from 3 months to 4 years. The primary patency rate was 21/22 (95%), and the secondary patency rate was 22/22 (100%). There was one amputation for ongoing gangrene in an ESRD patient with a patent bypass, resulting in an early limb salvage rate of 95%. For patients with inadequate conduit and tissue loss secondary to multilevel infrainguinal disease, simultaneous angioplasty with selective stenting of the SFA followed by distal vein bypass is a viable long-term solution that allows for limb salvage. Simultaneous performance is not associated with increased morbidity and decreases overall hospital use.     

Replacement of in situ saphenous venous aneurysms with arterial autografts

BACKGROUND: Aneurysm formation in arterialized autologous saphenous veins is an unusual complication of in situ femoral popliteal bypass procedures. METHODS: In a personal series of 207 in situ saphenous femoral popliteal bypass operations, three nonanastomatic venous aneurysms occurred. All three venous aneurysms occurred in male patients who had no adequate autologous vein available as an interposition graft. The use of eversion endarterectomized superficial femoral artery is reported as a substitute interposition graft with long-term results. RESULTS: In the 3 male patients in this series, nonanastomatic aneurysms developed in their in situ saphenous femoral popliteal bypass grafts. The venous aneurysms developed between 5 and 8 years after the original surgical procedure. No adequate vein was available as a replacement for the excised venous aneurysm. Prosthetic conduit was not used owing to the remote possibility of a subclinical infection. A segment of eversion thromboendarectomized superficial femoral artery removed from the same leg was used as a replacement interposition graft in each patient. The in situ venous graft with the autologous interposition thromboendarterectomized superficial femoral artery remained patent until each patient's death 4 to 7 years after the venous aneurysm replacement. CONCLUSIONS: A short segment of endarectomized superficial femoral artery has been found to be a novel solution for the treatment of isolated saphenous vein graft aneurysms when no suitable vein is available. These patients should be maintained on lifelong aspirin therapy owing to the thrombogenic potential of endarectomized artery.     

A novel approach: ascending venous arterialization for atherosclerosis obliterans.

OBJECTIVE: Lower limb arterial occlusion with no patent distal artery suitable for revascularisation is a common problem. The aim of this study was to assess the role of revascularisation to distal veins (ascending venous arterialization) in patients not reconstructable by conventional bypass. METHOD: Ascending venous arterialization is a distal arteriovenous fistula. Reversed great saphenous vein grafts, from above the knee, were anastomosed to the common femoral artery, superficial femoral artery or popliteal artery and distally to the saphenous vein at the level of medial malleolus. No intervention was done to destroy the venous valves. The great saphenous vein was ligated below the knee. In this way, oxygenated blood could reach to dorsal venous arch and the tissues below the knee in an ascending fashion through the great saphenous vein, which was not removed. RESULTS: All of the patients recovered immediately after the operation. The lesions on the feet and on the toes of the patients improved in a short time. Intermittent claudication of the patients disappeared. Strong pulses were detected on the dorsal venous arch with manual Doppler in 3 weeks. The below knee tissues were perfused with the applied technique. CONCLUSION: Ascending venous arterialization can be applied for limb salvage to the patients who do not have a suitable arterial bed to revascularize with conventional techniques.     

Endovascular obliteration of in situ saphenous vein arteriovenous fistulas during tibial bypass

Current methods of ligating venous branches during in situ vein tibial bypass are associated with significant wound complications, especially in diabetics. Making only proximal and distal wound incisions could avoid these wound problems. We report the use of endovascular techniques with coils and balloons guided by intraoperative arteriography and angioscopy to obliterate arteriovenous (AV) fistulas in three elderly diabetic patients undergoing tibial bypass. In all cases the proximal and distal vessels were first isolated and deemed suitable for bypass. The greater saphenous vein was prepared for the proximal and distal anastomosis, and angioscopically guided valvulotomy was performed. An introducer sheath was placed through a large proximal saphenous side branch for vascular access. With the use of fluoroscopy, AV fistulas were serially identified and cannulated with a guidewire. A guide catheter, passed over the wire into the side branch, served as the conduit through which coils and balloons were placed. Proximal and distal anastomoses were completed and arteriography performed. We were successful in obliterating AV fistulas in all three patients, but completion arteriography revealed additional AV fistulas requiring surgical ligation in two patients. Furthermore, operative time was increased by 1 1/2 to 5 hours. Two of three patients had wound infections, one at the proximal and one at the distal incision. All patients were discharged with a functioning bypass and no AV fistulas were seen on duplex scans. Endovascular obliteration of AV fistulas is feasible but is currently limited by prolonged operative time and incomplete obliteration.Presented in part at the Annual Winter Meeting of the Peripheral Vascular Surgical Society, Breckenridge, Colo., January 25–27, 1992, and at the Eleventh Annual Meeting of the Southern California Vascular Surgical Society, Dana Point, Calif., September 18–20, 1992.