The lower leg venous system consists of the superficial (greater saphenous vein) and deep (femoral vein) systems. Duplicated saphenous systems exist in the calf and thigh in approximately 25% of patients.

Distally, the greater saphenous vein can be found anterior to the medial malleolus. It crosses the tibia, runs medial to the knee, and ascends into the medial and posterior segment of the thigh as it descends medially into the common femoral vein in the groin (saphenofemoral junction).

In the thigh, the greater saphenous vein lies deep to the fascia (unlike accessory veins or tributaries). This may help discriminate the veins of the thigh during dissection.

In the proximal aspect of the thigh, the greater saphenous vein runs into the confluence of the superficial circumflex iliac vein, superficial inferior epigastric vein, and external pudendal veins to create the saphenofemoral junction. A useful anatomic landmark for the saphenofemoral junction is two fingerbreadths inferior and medial to the pubic tubercle.

Autologous vein graft is preferred to prosthetic graft, typically expanded polytetrafluoroethylene (ePTFE), in most locations, if there is a reasonable size match. A few notable exceptions to this are the aorta, common carotid, and subclavian arteries, if there is a clean field.

In the setting of a lower extremity vascular injury, use of the contralateral saphenous vein has been historically recommended because this strategy maintains venous collaterals and may theoretically reduce venous hypertension. This dogma has more recently been challenged as ipsilateral vein is used preferentially in elective lower extremity bypass.

Reversal of the vein is the most expeditious technique; however, some prefer nonreversal of the vein graft with the use of valvulotomy, especially if there is a significant size mismatch from the vein conduit to the recipient artery.

Careful handling of the vein graft is essential to prevent injury and subsequent graft failure.

Always leave the graft in situ until the proximal and distal sites for arterial anastomoses are properly exposed and deemed appropriate for bypass so as to ensure the vein graft is of adequate length and caliber.

Standard trauma prep-and-drape.

Keep the room warm and extremities covered to minimize peripheral venous vasoconstriction (up to the point of surgical preparation).

Sterile “bump” to prop up the knee for easier exposure of the saphenous vein and popliteal or tibial recipient arteries if desired.

Vascular tray and suture (5-0 and 6-0 double-armed polypropylene)

Ultrasound with 8 MHz probe (useful, but not absolutely necessary to mark out course of saphenous vein)

Fogarty balloons (size 3, 4, 5 French depending on artery size)

Vessel loops

Coronary dilators (2, 2.5, 3 mm)

Heparinized balanced electrolyte solution (5,000 units in 100 mL saline)

Topical papaverine

Nitrogylcerine (50–200 mcg/mL aliquots) for intraluminal injection in the case of severe vasospasm