Evaluation and Management of Peripheral
Vascular Injury
Part 2

Annotation for Point F

When debridement of an injured vessel or the injury itself results in significant segmental loss, an interposition graft of reversed autogenous saphenous vein or ringed polytetrafluoroethylene (PTFE or Teflon) is inserted.^17,18 The saphenous vein in the groin or at the ankle is preferred because it is an endothelium-lined conduit, is readily available, is a reasonable size match for most peripheral arteries and some veins, and, especially, has excellent long-term patency.¹⁷ When the greater saphenous vein is absent, is diseased (multiple stenoses), has a small diameter, or is the only venous outflow for an injured lower extremity, other options are available. The lesser saphenous vein on the posterior aspect of the leg is an ideal replacement because it has a muscular wall similar to that of the greater saphenous vein. Another option is to use the cephalic or basilic vein in the upper extremity as an interposition graft in the brachial artery. As these thin-walled veins dilate significantly when placed in the arterial system, ligation of branches during retrieval should be further from the vein than when the greater saphenous vein is retrieved. The time required to create a panel or spiral vein graft is usually excessive in the trauma patient, and these grafts are used rarely to replace injured peripheral vessels. Another option is to insert a PTFE graft, which is readily available off the shelf in appropriate sizes, is easy to sew, has a satisfactory patency when grafts with a diameter greater than 6 mm are used, and is remarkably resistant to infection in the absence of exposure or adjacent osteomyelitis.¹⁸ A newer version of an expanded PTFE graft has heparin molecules bonded directly to the luminal surface of the graft to reduce thrombosis, but there are not data on the use of these grafts in trauma vascular repairs.¹⁹ The presumptive value of using a ringed PTFE graft is in the support available when the surrounding reaction to the foreign body becomes a scar in the later postoperative period. All of the techniques described for an end-to-end anastomosis in E (heparinization, use of small vascular clamps, bulldog clamps, or vessel loops, passage of Fogarty balloon catheters, lack of tension on the anastomoses, a fine suture technique with 6-0 or 7-0 polypropylene, and flushing sequence) are used to complete the two anastomoses. It is helpful to complete the distal anastomosis first in a difficult anatomic location such as the distal tibioperoneal trunk near its bifurcation. This allows for better visualization of the posterior suture line and prevents narrowing of the orifices of the posterior tibial and peroneal arteries. The saphenous vein may not dilate enough to be a satisfactory interposition graft in the popliteal, femoral, common femoral, or axillary veins.With the concerns noted previously for panel or spiral vein grafts, an appropriately sized PTFE graft with external rings should be inserted and will have satisfactory short-term patency.²⁰