Alternative saphenous vein graft pathway from the femoral or supragenicular popliteal artery down to anterior tibial or dorsalis pedis artery

ABSTRACT

The classically described methods of a pathway from a supragenicular artery down to anterior tibial or dorsalis pedis artery graft routing are the medial [pre-tibial], the lateral [around the fibula neck], and the transosseous [through a window in the interosseous membrane]. In both medial and lateral approach, the graft is- vulnerable to compression around the knee joint bony elements. Regeneration of the interosseous membrane may narrow the arterial pathway. In the anterior leg compartment, the graft should ideally avoid compression as that induced by ischemia reperfusion edema, and be protected from exposure should a wound break down happens. Was to study efficacy and safety of modifications of saphenous graft routing, and minimizing number of incisions for distal artery and vein exposure, in anterior tibial or dorsalis pedis bypass. All study and control groups had critical foot ischemia. They consisted of two groups. Group I consisted of reversed vein graft [42 patients underwent the modified anatomical pathway, the graft was tunneled from the medial supragenicular incision, crossing above the interosseous membrane, pursuing the natural arterial pathway to the anterior compartment, passing deep to the muscles. A closed fasciotomy of the anterior compartment was performed to minimize the graft compression by the ischemia-revascularization edema, then performing the anastomosis to anterior tibial artery [ATA], or dorsalis pedis artery [DPA], and 10 controls underwent the subcutaneous lateral approach. Group II consisted of 20 cases done by in-situ saphenous vein bypass, using a single skin incision midway between the course of great saphenous vein [GSV] and [ATA] or [DPA] to serve both exposure of the artery, and harvesting of the distal segment of the GSV, and 10 controls, using double parallel incisions. The primary patency for the modified anatomical tunneling technique was, 85.71%, with no need for further surgery to assist patency. The limb salvage was 84.3%. Meanwhile, for the lateral subcutaneous tunneling the primary patency was 60%. Three cases during the follow up period needed revision with resultant success of only two cases making the cumulative patency 50% and with limb salvage rate of 50%. Eighty four% of the patients were diabetics, follow up time was 2-7 years. Using a single incision for distal artery exposure and saphenous vein release when using the in-situ technique in this study yielded infection rate of 5% compared to 20% in the double incision technique. Also, the patency rate was 80% compared to 60% in the double incision technique. The relative safety and efficiency of the alternative saphenous vein graft pathway in achieving a good patency rate and less complications in anterior tibial or dorsalis pedis bypass can be shown in this study