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The open proximal end of the saphenous vein is tailored to match the arteriotomy. The edges of the tip may be removed to create a more oval taper and the vein may be opened in a longitudinal direction posteriorly to create a larger opening if needed. The anastomosis is performed with a 6-0 monofilament polypropylene suture that is double-ended with a needle at each end. As shown in Figure 7A, the course of each stitch in this running suture begins by entering the vein from the outside to lumen and proceeds from lumen to outside on the artery. This avoids raising an intimal flap in the artery, since the point of the needle is always pressing the intima onto rather than off the arterial wall. The suture line is begun with a mattress-type suture at the “heel” end of the vein (Figure 7). The lateral or far side is run first and brought around the tip or “toe” end to join the medial or near-side suture in the midportion (Figure 8). The anastomosis is flushed with heparinized saline, and the sutures are tied.

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The arterial vessel loops are released, and the proximal saphenous vein will dilate with a pulsatile arterial inflow that stops at the next venous valve about 4 to 6 cm downstream. A retrograde valvulotome is introduced into the saphenous vein via a venotomy in a small side branch (Figure 9). The blunt-tip valvulotome is positioned above (proximal to) each competent valve in the inflated proximal section and then rotated and withdrawn separately through each anterior and posterior valve. It is important that the valve be inflated and that the retrograde valvulotome be positioned to cut perpendicularly to the plane of the skin as the valve leaflet lies parallel to the skin surface (Figure 10). Several passes are often needed. When the valve is successfully cut, the proximal inflation will proceed distally to the next valve. The distal vein is marked longitudinally with ink to ensure against rotation.

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When all the valves have been successfully cut, ...

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