Use of the in-situ lesser saphenous vein bypass from popliteal to peroneal artery.

Lesser saphenous vein grafts have become an important element in limb salvage surgery. Their location frequently dictates that the graft be translocated for use. This incurs the disadvantages of ischemia and increased manipulation of the graft and loses the advantages of an in-situ bypass. The use of the lesser saphenous vein as an in-situ graft for tibial artery reconstruction offers the advantages of reduced vein graft injury and improved patency. Technical requirements for an in-situ lesser saphenous bypass include that graft inflow be based on the popliteal artery, the vein length suffice to reach the target artery, and the runoff vessel have adequate size, length, and collateral connections to allow reasonable likelihood of success. The surgical approach requires the patient be in a prone position allowing a posterior longitudinal incision in the leg. Exposure of the distal portion of the peroneal artery is accomplished by separating the peroneus brevis and flexor hallucis longus. The peroneal artery is then visualized when the fibular attachments of the flexor hallucis longus are divided. Our experience indicates that the lesser saphenous vein may be successfully used as an in-situ conduit for bypass to the distal peroneal artery. Technical innovations such as flexible valvulotomes with detachable heads, and tourniquet control of bleeding facilitate the operation. A posterior approach to the popliteal and crural arteries affords the ability to use the lesser saphenous vein as an in-situ bypass.