Abstract: Saphenous vein grafts are the preferred conduit for femoropopliteal and femorotibial arterial reconstruction. When saphenous vein is not available, arm vein grafts have proved to be a suitable alternative.1Harris W Andros G Dulawa B Oblath R Salles-Cunha S Apyan R. Successful long-term limb salvage using cephalic vein bypass grafts.Ann Surg. 1984; 200: 785-792Crossref PubMed Scopus (61) Google Scholar Usually the cephalic or basilic vein is taken from the wrist to the axilla and used as a reversed vein graft. Often, however, these veins are too narrow to form a satisfactory conduit, especially in the forearm. We have devised a technique that takes advantage of the larger diameter segments of the cephalic and basilic veins in the upper arm. The result is a larger diameter vein graft that is long enough for distal arterial reconstruction. It is essential to this procedure that the median cubital vein, which connects the cephalic and basilic segments, is patent. In the current small series we have been able to determine this on the basis of physical examination alone. We tap with a finger over the patent median cubital vein and simultaneously palpate along the cephalic and basilic veins for the transmitted pulse wave; at times we have used a Doppler probe to detect the transmitted pulse wave. These techniques have been satisfactory in our experience thus far. However, it is possible that phlebography might be helpful and we recommend this if there is uncertainty about the patency of the median cubital, cephalic, and basilic veins in the upper arm. The entire upper extremity and base of the neck must be prepared for surgery so that the full length of cephalic vein can be used. Perivenous infiltration is performed as the vein is exposed, with a warm (35° to 40° C) papaverine solution (60 mg papaverine and 2000 units heparin in 500 ml of Plasmalyte) to prevent venospasm. This is the same technique we use for saphenous vein grafts and has been described in detail previously.2LoGerfo F Haudenschild C Quist W. A clinical technique for prevention of spasm and preservation of endothelium in saphenous vein grafts.Arch Surg. 1984; 119: 1212-1214Crossref PubMed Scopus (45) Google Scholar Other than to note that the cephalic vein is somewhat thin-walled and delicate, the dissection is identical to that for saphenous vein grafts. Once excised, the vein graft is distended with a commercially available distention set (Shiley, Inc., Irvine, Calif.) containing the papaverine/heparin solution.2LoGerfo F Haudenschild C Quist W. A clinical technique for prevention of spasm and preservation of endothelium in saphenous vein grafts.Arch Surg. 1984; 119: 1212-1214Crossref PubMed Scopus (45) Google Scholar The valves of the basilic and median cubital veins are lysed with a valvulotome introduced through the stump of the cephalic vein where it has been divided in the upper forearm. A standard metal valvulotome (Pilling, Inc., Fort Washington, Pa.) is used. The first valve at the central end of the basilic vein is quite large and may be difficult to cut with the valvulotome. In that case we have everted the central end of the vein and excised the valve with a scissors under direct vision. After the valves are incised, the vein is distended with the balloon distension device and stored in cold plasmalyte/papaverine heparin solution until ready for implantation. The femoral anastomosis is made with the proximal portion of the larger basilic vein and the distal anastomosis with the cephalic vein. The valves in the basilic portion of the vein graft have been incised, so that this segment of the vein graft can be used in the “nonreversed” orientation. However, because the cephalic vein is placed in a “reversed” orientation, it is not necessary to incise the valves in that segment of the graft (Figs. 1-4).Fig. 2Harvesting of arm veins with mobilization of basilic vein to become the inflow segment. The end of the vein is cannulated to facilitate subsequent valvulotomy. Before cannulation the end of the basilic vein may be everted so that the first valve can be excised with a scissors.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig. 3Valves of the distended basilic vein are incised with a valvulotome inserted through the stump (b) of the divided cephalic vein.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig. 4The vein bypass graft in position. The proximal basilic segment is in the “nonreversed” orientation while the distal cephalic segment is in the “reversed” orientation.View Large Image Figure ViewerDownload Hi-res image Download (PPT) We have found this new arm vein graft to be sufficiently long to reach at least the midtibial level and have used it in eight patients. These procedures included four common femoral-to-distal popliteal grafts and four common femoral-to-peroneal or tibial grafts. One of the femoropopliteal grafts failed at 5 months; all the other grafts are patent at intervals up to 1 year. This is small series that serves to illustrate the practical application and advantages of this technique. We expect the performance of these grafts to be as good as that of reversed arm vein grafts and perhaps better because of the larger diameter of the upper arm veins. Furthermore, there is less size mismatch at the anastomosis with the large basilic vein to the common femoral artery and the smaller cephalic vein to the popliteal or tibial artery. The technique is limited to distal reconstruction when no saphenous vein is available and the upper arm veins are patent. When these conditions are present, we have found this to be an important new tool for distal arterial reconstruction and have been sufficiently encouraged to recommend its use to others.