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The tendinous portion of the medial head of the gastrocnemius muscle may be incised sharply, if necessary, to prevent compression of the graft at that point (Figure 13). A tunnel is fashioned from the femoral triangle through to the proximal popliteal space by similar blunt dissection in the subsartorius muscle plane. These tunnels are marked with Penrose drains (Figure 13).

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The patient is systemically anticoagulated with heparin. The popliteal artery at the site chosen for anastomosis is occluded proximally and distally. The arteriotomy site is carefully chosen distally to a point beyond significant disease to ensure adequate runoff. The artery is incised with a small-bladed knife and the arteriotomy completed with Potts scissors (Figure 14). A Fogarty catheter (size 3 or 4) may be passed distally to ensure distal artery patency. The proximal larger end of the saphenous vein graft is then tailored to match the popliteal arteriotomy. The vein is incised longitudinally (Figure 15), and the edges of the tips are removed to create a “cobra-head” tip (Figure 16). The distal anastomosis is started with a mattress suture of double-ended 6-0 polypropylene at the heel of the graft (Figures 17 and 18). The anastomosis is then begun by running one end of the suture toward the midpoint of the anastomosis, using a running continuous technique proceeding from outside-in on the vein and inside-out on the artery to avoid elevating an intimal flap (Figures 19 and 20).

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