Autologous vein bypass conduit for distal bypass confers preferable outcomes to prosthetic or biological grafts. In the absence of suitable ipsilateral or contralateral great saphenous vein (GSV), arm veins and small saphenous vein (SSV) can be used. However, these are often limited by conduit length and arm vein harvest is associated with considerable morbidity. To achieve sufficient length these veins often need to be spliced together. The Giacomini vein is a cranial extension of the SSV and has been reported to occur in up to 70% of patients yet there is a dearth of reported cases in the literature of this being used as a bypass conduit.

CINAHL and PubMed were searched for the following terms 'Giacomini vein' and/ or 'thigh extension of SSV', and 'vascular bypass' and/ or 'bypass conduit'. Current case reported on.

Only 2 cases of Giacomini vein use as a bypass conduit have been reported in the literature. Only one case required the additional length achieved by using the Giacomini vein to gain sufficient length for a superficial femoral artery (SFA) to anterior tibial artery (ATA) bypass that could not have been achieved with SSV or arm vein. A 51-year-old patient presented as an emergency with an infected mixed aetiology left gaiter ulcer. He had 2 years previously undergone bilateral radiofrequency ablation of his GSV and had evidence of old thrombus within the upper aspect of his ipsilateral SSV on pre-operative venous duplex. Arm duplex showed adequate calibre cephalic vein (CV) from his wrists to his upper arms. CT angiogram demonstrated a small common femoral artery (CFA) aneurysm, heavily diseased SFA and popliteal artery, tibio-peroneal trunk (TPT) occlusion with reconstitution of flow in his posterior tibial artery (PTA) as single vessel run-off into his foot 10 cm proximal to his ulcer. He required approximately 55cm of conduit length. In view of his infected leg ulcer the use of prosthetic conduit was contra-indicated and the options we considered were Omniflow II with vein cuff or splicing CV from both arms or a composite prosthetic-arm vein conduit. On review of his CT, he had a Giacomini vein extending from his popliteal fossa up his posterior thigh, which then extended up anteromedially and inserted into his GSV just proximal to his saphenofemoral junction (SFJ). After measuring and marking the patient (Fig 1), his Giacomini vein was between 4-5mm diameter and appeared to be ~50cm in length. The vein was harvested with the patient in the left lateral position from popliteal fossa to upper thigh and then the vein was flushed with heparinised saline and tucked underneath the upper extent of the posteromedial thigh wound before the skin was closed and dressed. The patient was then positioned supine and the leg was prepped and draped as per standard practice. The upper posteromedial wound was then re-opened, and vein harvested up to the SFJ. After exposure of the femoral vessels and PTA, an anatomical tunnel was fashioned and a long tie was used to measure the required length of conduit and his Giacomini vein was then reversed and tunnelled. His distal anastomosis was started to maximise the vein length and then a proximal anastomosis onto distal CFA was performed. Postoperative recovery was steady with biphasic signals over the graft and the PT at ankle. His wounds showed satisfactory healing in progress. He started mobilising two days later, albeit with analgesia. He is receiving ongoing care for the leg ulcer.

In the absence of GSV, Giacomini vein, if present, should be considered as an alternative to upper limb vein when there is insufficient length to avoid a composite graft.

1. Delis KT, Swan M, Crane JS, Cheshire NJ. The Giacomini vein as an autologous conduit in infrainguinal arterial reconstruction. J Vasc Surg. 2004;40:578-581. [PubMed] [Google Scholar]