INDICATIONS An arterial injury, which cannot be repaired in any other way, and cannot be tied for fear of causing gangrene—see Section 55.2.
REVERSED SAPHENOUS VEIN GRAFT Expose the patient’s saphenous vein through an adequate incision along its length.
Remove a suitable length of vein, and cut off all its side branches between 4/0 monofilament ligatures.
Remove the isolated segment of vein, clamp its distal end with a haemostat, and irrigate it with heparinized saline (55.6) under pressure. This will show up the leaks from any small side branches you may have have missed. It will also distend the vein most usefully, but take care not to distend it too much.
Leave it distended with heparin and lying in some heparin or blood while you prepare the artery to receive it.
Trim the ends of the veins and anastomose them to the artery, using the method described above for anastomosing an artery. The piece you take may have a valve in it, so make sure you reverse the direction of the flow of blood in it.
Remove the distal arterial clamp just before the last stitch or two, so that any air caught inside the repair can escape through the hole between your last two sutures.
Leave the repair under a warm saline pack while you wait 10 minutes. Inspect it, and if it looks satisfactory, cover it with adjacent tissue and close the wound, preferably by delayed primary closure.
SAPHENOUS VEIN PATCH GRAFT Take a piece of saphenous vein, open it out, make quite sure the intima faces inwards, and patch it in place with fine sutures. If you fail, you will have to tie the patient’s injured vessel. If his limb becomes gangrenous, amputate it.
