Complex redo surgical revascularisation for progressive atheromatous disease in lower limb arteries

We present the case of a man in the 50s with a decade-old history of surgical revascularisation for aortoiliac and femoropopliteal occlusive disease, who presented with new-onset critical limb ischaemia in the right lower extremity. A CT angiography revealed occlusion of the prior prosthetic femoropopliteal bypass graft and progression of atherosclerosis into the tibioperoneal segment, the distal vessel being patent but small-calibre posterior tibial artery. Considering the patient's extensive vascular history, vessel calcification and unsuitability for further prosthetic grafting, a redo bypass from the right common femoral artery to the posterior tibial artery was performed using a reversed great saphenous vein from the contralateral leg. Postoperative recovery was uneventful with return of distal pulses and symptomatic relief. This case highlights the importance of utility of saphenous vein graft not just in coronary artery disease, but also in surgical revascularisations in lower limb arteries that can be complex owing to their small size where prosthetic graft usage is not feasible.