The initial incision, which follows the course of the greater saphenous vein (Figure 1), is made vertically across the inguinal crease, and early identification is made of the greater saphenous vein at the fossa ovalis. Dissection is continued distally in a progressive fashion to expose the entire length of vein required for the bypass. Alternatively, multiple incisions with intervening skin bridges may be elected. The creation of large skin flaps must be avoided to prevent skin necrosis and serious wound problems. After exposure of a suitable length of saphenous vein (Figure 2), the venous tributaries are doubly ligated proximally and distally with 0000 silk suture, or proximally with 0000 silk suture and distally with a medium silver clip, and divided (Figure 3). Flow is maintained with both ends intact as tributaries are ligated. Precautions are taken not to gather venous adventitia by ligating these tributaries excessively close to the vein wall, which will result in stenosis of the bypass graft (Figure 4). The vein should be kept in situ with flow maintained until just before the bypass graft is to be performed. After the saphenous vein is removed, a ball-tipped needle is inserted into the distal lumen (Figure 5) to permit flushing and distention during graft preparation (Figure 6). The proximal vein is then clamped gently with a bulldog clamp, and the vein is distended gently with cold autologous heparinized blood. This maneuver reveals leaks resulting from division of unidentified tributaries and stenotic areas that may require attention. Overdistention by forceful irrigation is avoided, as this may irreversibly damage the vein graft. At the completion of vein distention, an ink line is drawn down the graft to help avoid twisting the segment as it is brought through the tunnel later in the procedure (Figure 7). The femoral arterial exposure is performed as for aortofemoral bypass grafting with tapes passed around the common femoral artery proximally, the profunda femoris artery, and the superficial femoral artery (Figure 8). Care is taken to ligate the overlying lymphatic tissue to prevent formation of a lymphocele or lymph fistula.