In situ saphenous vein bypass: prevention and management of early complications

Since adopting the in situ, non‐reversed saphenous vein technique for bypass procedures in the leg early in 1986, 50 bypasses have been performed in selected patients, primarily for limb salvage. A Mills valvulotome was used for retrograde disruption of the saphenous valves, after exposure of the whole length of vein. Significant peri‐operative complications occurred in nine patients and were strongly associated with technical factors. Early graft occlusion (n= 2) and residual arteriovenous fistulae (n= 2) were revised by timely reoperation, resulting in early (30 day) patency of all but one graft. In seven patients, angioscopic visualization of the valve division process was tested as a method of ensuring complete valvulotomy, while avoiding trauma to the vein wall. Distal anastomosis to the popliteal artery above the knee or close below the knee caused a considerable degree of graft angulation, which was exacerbated by flexion of the leg, whereas anastomosis to the more distal popliteal artery or tibial vessels resulted in a favourable curvature of the graft. Lessons learned during this initial experience and aspects of technique for prevention of complications are presented.