Peripheral Artery Disease And A-v Flstula

Fig. 7.5. Linear slit arteriotomy for end to side anastomosis.

2. The short saphenous vein is thin-walled in comparison with the long saphenous vein, usually has a nearly constant diameter throughout its length and presents no problems with direct end-to-end anastomosis with the vessels of most transferred flaps.

3. The vein most of the time may be left in situ at its upper end. This reduces the amount of dissection necessary, avoids one anastomosis and provides double drainage into both the superficial saphenous system and the deep popliteal and femoral systems. This is of importance in patients who have impaired outflow secondary to deep venous thrombosis or obstruction.

4. Flexibility of vein graft permits placement of free flaps where desired, independently of the length of the free flap vascular pedicle and of the condition of regional vessels.

5. The separated vein graft components permit accurate separable ultrasonic Doppler monitoring of both the artery and the vein and so should give prompt warning of venous occlusion—the usual cause of free flap loss.

Fig. 7.6. Short saphenous vein A-V loop.

The use of temporary arteriovenous fistula has the advantage of providing continuous flow through the graft until the free flap is in place and ready to have its circulation restored with end-to-end anastomoses. Cessation of flow then should be brief. The flexibility of short saphenous vein grafts for complicated free flap reconstructive procedures in the lower extremity is impressive. The long saphenous vein is also useful when a free flap is needed in the thigh or lower abdomen. Its upper end may be left intact at the fossa ovalis and the lower end anastomosed to the femoral artery or to one of its branches setting up a temporary A-V fistula.16

Flap survival is not related to the use or the length of vein grafts, but rather to the severity of the condition responsible for the tissue defect.

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