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INTRODUCTION

Atherosclerosis is a leading cause of peripheral artery disease (PAD) which can be silent or present with a variety of symptoms and signs of ischemia. Ideal treatment includes a multidisciplinary approach involving the vascular surgeon, primary care provider, podiatrist, and plastic surgeon. The goal of the treatment is to prevent further progression of the disease using lifestyle modification and to reestablish blood flow to the affected end organ. Traditionally, the open surgical bypass was the only option to reestablish perfusion. Currently, percutaneous endovascular therapy adds a very reliable and attractive option with lower morbidity and mortality. Yet, both approaches to revascularization are important and necessary as part of an aggressive limb salvage program and are core skills for any vascular surgeon. In this chapter, we will discuss the different available bypass conduits, their characteristics, patency, and factors affecting their patency.

AUTOGENOUS VEIN GRAFTS

In general, autogenous conduits are the preferred option for vascular bypass, with great saphenous vein proving to be the most durable, but their use may be limited by the availability of suitable veins of appropriate diameter, length, and quality. In this section, we describe both upper and lower extremity venous options which can be used for arterial bypass.

Lower Extremity Veins

In the lower extremity, there are three veins group: The deep veins (within the muscular compartments), the superficial veins (between the dermis and superficial to the muscular fascia), and the perforators which connect the other two groups. The superficial veins include the great saphenous vein (GSV, the greater or long saphenous vein) and the small saphenous vein (SSV, the lesser or short saphenous vein). The GSV runs between the superficial and aponeurotic deep fascia (Figure 13-1).1 It begins just anterior to the medial malleolus, crosses the tibia, traverses medial to the knee, ascends in the medial-posterior aspect of the thigh to the groin, and then enters the fossa ovalis (approximately 4-cm inferior and lateral to the pubic tubercle) to drain into the anterior surface of the common femoral vein. The SSV begins lateral to the Achilles tendon in the calf. It runs posteriorly in the calf, pierces the muscular fascia, and courses between the medial and lateral heads of the gastrocnemius and joins the popliteal vein in the popliteal fossa about 5-cm proximal to the knee crease.

FIGURE 13-1

In a transverse view, the saphenous eye or “Egyptian” eye is featured with the LSV located between the superficial and aponeurotic deep fasciae. (Reproduced with permission from Chen SS, Prasad SK. Long saphenous vein and its anatomical variations. Australas J Ultrasound Med. 2009;12(1):28-31.)

Upper Extremity Veins

Two groups have been described in the upper extremity: the superficial (cephalic vein, basilic vein, and the median cubital vein) and ...

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