Staged in situ bypass

Abstract

Background: After femoral revascularization, following embolectomy or proximal reconstruction, the need for additional distal revascularization may be unpredictable. This dilemma may be addressed by anastomosing the detached upper end of the long saphenous vein to the femoral arteriotomy, as for in situ bypass, permitting some outflow into proximal vein tributaries. Later, if ischaemia persists, distal arterial flow can be established by closed retrograde saphenous valvulotomy. Methods: Over 12 years this technique was employed in 26 legs in 22 patients, following inflow reconstruction in 15 and femoral embolectomy in seven. Postoperative observation showed persisting distal ischaemia in 14 legs and distal bypass was completed after 1–9 days, using local anaesthesia without femoral re‐exposure. One patient died at 15 days and 13 grafts were patent on discharge from hospital. Results: In 12 legs in 11 patients, limb perfusion was deemed adequate after operation. Four patients (five legs) died in hospital and seven were discharged. No further procedure was required in five and the proximal long saphenous vein presumably thrombosed. In two legs the whole long saphenous system had become pulsatile at 7 and 8 months, and a distal bypass was completed. No amputations were required in this series. Conclusion: Staged in situ bypass can avoid prolonged and complex reconstructions in frail patients and facilitates the use of local anaesthesia, where necessary. © 2000 British Journal of Surgery Society Ltd