Technique for Thrombectomy of Reversed Saphenous Vein Arterial Bypass Grafts D. Preston Flanigan, MD,* Chicago, Illinois James J. Goodreau, MD,+ Bethesda, Maryland Steven J. Burnham, MD,* Chapel Hill, North Carolina

Since its initial use by Kunlin [1,2], the reversed saphenous vein has become the graft material of choice for femoropopliteal and tibia1 artery bypass. The incidence of immediate postoperative thrombosis of autogenous saphenous vein bypass grafts has been reported to be as high as 10 to 20 per cent [3,4] and has been most commonly due to technical error [3]. Immediate reoperation with thrombectomy and correction of technical errors has often been successful in yielding long-term patency. Although the Fogarty balloon catheter technique [5] is easily applied to arterial embolectomy, thrombectomy of a reversed saphenous vein used as an arterial bypass is limited by the presence of unidirectional valves. Passage of a catheter cephalad from a distal venotomy is impeded by these valves (Figure lB), as is withdrawal of the inflated balloon if the catheter is passed distally from a venotomy over the proximal anastomosis (Figure 1C). Although repeated attempts at passage of the catheter often result in success, unnecessary damage to the vessel may occur, possibly reducing the chance of long-term patency. autogenous

catheter is gently passed distally through the proximal venotomy, thus pushing the thrombus ahead of it and out the distal venotomy site (Figure 1, A and D). Adequate distal arterial occlusion is maintained so that thrombus is not pushed into the distal arterial tree. Thrombus is then removed from the distal arteries with the balloon catheter in the standard fashion. The graft is irrigated with heparinized saline, and the venotomies are meticulously closed with 6-O or 7-O polypropylene (Prolene@, Ethicon Inc.) suture. Operative arteriography is routinely performed. This technique has been uniformly successful in the removal of thrombus and is a definite improve-

Technique

When postoperative thrombosis of a graft is documented, the patient is immediately heparinized and returned to the operating room. Both the proximal and distal anastomoses are explored through venotomies in the graft over these areas. Technical errors, if found, are corrected. An inflated no. 3 or 4 Fogarty From the Department of Peripheral Vascular Surgery, Northwestern University Medical School, Chicago, Illinois. * Present address and address for reprint requests: Department of Surgery, University of Illinois at the Medical Center, P.O. Box 6998, Chicago, Illinois 60680. + Present address: Division of Vascular Surgery, Bethesda Naval Hospital, Bethesda, Maryland. t Present address: Peripheral Vascular Disease Laboratory, University of North Carolina Medical School at Chapel Hill, Chapel Hill, North Carolina.

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Figure 1. Illustration of the technique for thrombectomy of reversed saphenous vein arterial bypass grafts.

The American Journal of Surgery

Thrombectomy

ment over previous methods. There have been no complications related to the catheter. Also, venotomy over both anastomoses allows direct visual inspection of the anastomotic areas. Long-term graft patency is obviously affected by early postoperative success. This technique provides a technically simple and relatively atraumatic method of reestablishing graft flow in the early postoperative period, thus providing a better opportunity for achieving long-term patency of the graft. Summary

A technique for thrombectomy of saphenous vein arterial bypass grafts is described. The technique

Volume 138, August 1979

includes visual inspection of both anastomoses and avoids unnecessary trauma to the graft secondary to repeated attempts at passing a balloon catheter against the direction of the venous valves. References 1. Kunlin J: Le traitement de I’arterite obliterante par la greffe veineuse. Arch Mal Coeur 42: 37 1, 1949. 2. Kunlin J: Le traitement de I’ischemie arteritique par la greffe veineuse longe Rev Chir 70: 206, 195 1. 3. Garrett HE, Ketch PI, Green MT, Diethrich EB, DeBakey ME: Distal tibia1 artery bypass with autogenous vein grafts. Surgery 63: 90, 1968. 4. Tyson RR, Reichle FA: Bypass to tibia1 or popliteal arteries in severely ischemic legs. Ann Surg 176: 3 15, 1965. 5. Fogarty TJ, Cranley JJ, Krause RJ, Strasser ES, Hafner CD: A method for extraction of arterial emboli and thrombi. Surg Gynecol Obstet 116: 241, 1963.

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Technique for thrombectomy of reversed saphenous vein arterial bypass grafts.

Technique for Thrombectomy of Reversed Saphenous Vein Arterial Bypass Grafts D. Preston Flanigan, MD,* Chicago, Illinois James J. Goodreau, MD,+ Bethe...
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