Complete graft eversion as a rescue maneuver for salvaging a thrombosed vein graft

When an autologous vein graft, such as a great saphenous vein bypass, thromboses, it can be very difficult to salvage. This is quite different from a prosthetic graft. In a PTFE graft, a standard Fogarty thrombectomy may often restore an acceptable lumen. In a vein graft, however, thrombus may remain adherent to the irregular intimal surface, valve pockets, stenotic segments, or areas of technical imperfection. Even small residual thrombus can rapidly lead to rethrombosis.

For this reason, a thrombosed vein graft should not be treated as a simple “Fogarty job.” The cause of thrombosis must be identified and corrected: inflow, outflow, distal runoff, anastomotic stenosis, kinking, retained valves, or technical defects. In many cases, the best option is to look for another suitable conduit and perform a new bypass.

However, if the occlusion is very recent — around 24 hours, or only slightly longer — there may be a way to save the graft. One useful rescue technique for salvaging this thrombosed vein graft is complete eversion.

The steps are as follows:

1. Expose both the proximal and distal anastomoses.
2. Disconnect the graft from the native arteries by carefully cutting the polypropylene sutures of both anastomoses.
3. Thrombectomize and flush the donor and recipient arteries using standard methods: Fogarty catheter, heparinized saline, and, when appropriate, local thrombolytic adjuncts according to protocol, especially for the distal arterial bed.
4. Flush the vein graft thoroughly with heparinized saline to remove as much thrombus as possible.
5. To make sure that no thrombus remains attached inside the graft, fully evert the vein. Start from the larger end. With delicate forceps, gently grasp the intimal edge and progressively turn the graft inside out, advancing little by little.
6. Once approximately half of the graft has been everted, a simple trick can help with the remaining segment. Flush the already everted portion with heparinized saline using a 20 ml syringe. With controlled pressure, the remaining non-everted segment may evert rapidly.
7. Once the entire graft is everted, inspect and carefully clean the intimal surface. Remove any adherent thrombus using gentle forceps and repeated saline rinses.
8. If the graft was not previously valvulotomized, thrombus may remain trapped beneath valve cusps. All valve cusps should be carefully divided, for example with fine Potts scissors, while avoiding injury to the vein wall.
9. After the graft has been completely cleaned, turn it back to its normal orientation, again starting from the larger end and using the same gentle eversion technique in reverse.

This maneuver is not for every thrombosed vein graft. It is mainly a selective bailout option for very recent occlusion, when the conduit is still worth preserving and no better vein is available.

But in the right case, complete graft eversion can transform a thrombosed vein graft from an unusable conduit into a graft that may still be suitable for redo bypass. The graft should only be reused if, after cleaning and reorientation, it appears macroscopically intact, non-dissected, and technically suitable.