[Technique for endoscopic vein preparation in infra-inguinal in situ bypass]

In situ saphenous vein bypass for infrainguinal reconstructions achieves excellent results, especially for distal anastomoses. The achilles heel of the method is the complete and atraumatic disruption of the valves and the location of significant tributaries of the saphenous vein. An intraoperative quality control is necessary to mend early patency rates. Several control instruments are described: intraoperative arteriography, duplex- or Doppler sonography and angioscopy. We describe the technique of a semiclosed angioscopy guided technique with a novel flushing valvulotome. We use an angiofiberscope with 2.2 or 1.4 mm outer diameter, being introduced through the proximal exposed end of the saphenous vein. Through the distal end or a side branch a modified Mill's valvulotome with a flushing channel (flexible or non flexible) is moved upwards to the angioscope. Every valve cusp is incised under direct vision in a retrograd direction. Simultaneously relevant tributaries are angioscopically located and ligated through small skin incisions. To use the potential of angioscopy we have developed the occluder valvulotome, making endoluminal embolization of tributaries of the saphenous vein possible. Details of these techniques are described.