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Synergizing Antegrade Endoscopic with Bridging Vein Harvesting for Improvement of Great Saphenous Vein Graft Quality from the Lower Leg
Published on: November 19, 2019
In situ saphenous vein bypass--forty years later
1Department of Surgery, University of California at Irvine, Orange, CA 92868-3298, USA. jeconndl@uci.edu
Insights
In situ saphenous vein bypass offers hemodynamic advantages over reversed grafts, particularly for below-knee bypass surgery. Preoperative mapping and refined techniques improve outcomes for this widely used vascular procedure.
Area of Science:
- Vascular Surgery
- Cardiovascular Science
Background:
- Saphenous vein bypass grafting is a common surgical procedure for peripheral artery disease.
- In situ saphenous vein bypass, introduced in 1962, has become a key alternative to reversed saphenous vein bypass.
- This review examines the current standing and techniques of the in situ saphenous vein bypass procedure.
Observation:
- The in situ technique offers superior hemodynamic flow due to converging vein walls and better vein-to-artery size matching compared to reversed grafts.
- While reversed grafts may suffice for popliteal artery bypass due to comparable vein diameters, the in situ method is favored for groin-to-ankle bypass.
- Controversies include the efficacy of valvulotomes for valve lysis and the choice between open versus closed surgical approaches to minimize skin complications.
Findings:
- Preoperative vein mapping is beneficial for all saphenous vein bypass operations.
- Open in situ procedures benefit from skin bridges and precise incisions guided by mapping to reduce complications.
- Endoscopic techniques offer advantages but require experienced surgeons; valve lysis methods have improved but remain imperfect.
Implications:
- The in situ saphenous vein bypass remains a valuable technique, especially for distal bypasses, with ongoing refinements in surgical approach and valve management.
- Improved preoperative assessment and surgical technique, including minimally invasive options, enhance the safety and efficacy of saphenous vein bypass grafting.
- Further advancements in valve lysis and endoscopic techniques could further optimize outcomes in in situ saphenous vein bypass surgery.
Abstract:
In situ saphenous vein bypass, which was performed first by Rob in 1959, but introduced by Hall in 1962, has been widely applied as an alternative to the reversed bypass. Now, forty years later, it seems appropriate to review its current place and technique. Of the presumed original benefits of the in situ operation, it is now clear that the hemodynamic flow of converging (in situ) versus diverging vein (reversed) boundaries plus better vein/artery size match are the main advantages. It is now popular belief that the reversed saphenous vein graft to the popliteal artery has no significant hemodynamic disadvantage because the vein is of comparable diameter at the knee and in the groin. In contrast, vein bypass from the groin to the ankle strongly favors the in situ procedure because of the convergence of the walls of the vein below the knee and better vein/artery size match. The most controversial facet of the in situ operation has been the question of valvulotome is superior to lyse valves and whether to perform the operation open as originally described, or closed to avoid skin complications from a long groin to ankle incision. Preoperative vein mapping is advantageous for all saphenous vein conduit operations. For open leg in situ procedures, skin bridges and incisions made directly over the vein, directed by mapping, will minimize skin complications. Use of endoscopic in situ techniques is ideal but only with an experienced endoscopist. Valve lysis has improved but is still not foolproof.
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