Introduction:

In situ lesser saphenous vein (LSV) graft has been advocated in cases of lower limb revascularization where target arteries are confined to the lower leg and the greater saphenous vein (GSV) is neither available nor suitable. This often occurs in diabetic or end-stage renal diseased patients, whose occlusive disease pattern typically affects the tibioperoneal vessels, sparing the femoropopliteal segment. In situ technique offers the potential advantages of decreased surgical trauma to the vein, better size-matching and improved hemodynamics. The posterior approach simplifies the surgical procedure; it achieves similar graft patency and limb salvage rates compared to standard procedures.

Case report:

We report a case of an 89 years-old male diabetic patient with previous attempts of endovascular revascularization of the posterior tibial and peroneal arteries; he presents with a nonhealing ulcer of the first toe of the right foot. Ultrasonographic vein mapping revealed varicose GSV in both limbs and a linear, ~3mm diameter, LSV in the right leg. The patient underwent right limb retrogeniculate popliteal to distal posterior tibial artery bypass with in situ LSV through a posterior approach. Post-operative bypass thrombosis occurred after seven days; it was resolved with surgical thrombectomy, vein angioplasty and arteriovenous shunt ligation. During follow-up at the outpatient clinic, the bypass remains patent and skin lesions healing without complications.

Conclusion:

In situ LSV is a safe and viable option conduit for popliteal to distal arteries bypasses. Vascular surgeons should be aware of the posterior approach, which simplifies and comfortably exposes the anatomic structures required for this surgery.

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