used intraoperatively. Subcutaneous heparin is used postoperatively but not preoperatively as systemic heparinisation is used routinely on aortic clamping. [Q6: A, B, C, F]

In cases where a prosthetic graft has been exposed in the groin or the tissues overlying a femoral anastomosis are deficient, a local muscle flap is wise to protect the new femoral anastomosis. [Q8: D] A sartorius rotation flap may be used provided the graft does not extend in front of the inguinal ligament as in femoral-femoral or axillofemoral grafts.44, 45 Gracilis and rectus abdominis flaps or omental pedicles have also been described.46–51 A rectus femoris flap is very quick and easy to prepare and will cover any femoral anastomosis with ease.38 In occasional localised low-grade graft infections with exposure of the prosthesis in the groin, a simple muscle flap may be successful without excision of the graft but there is a high rate of recurrent infection.

Despite the magnitude of the procedure, graft replacement with femoral vein gives excellent results with reported mortalities in the region of 10%, amputation rates of 10% and no reinfection. Possible complications include anastomotic haemorrhage, iliac venous thrombosis, limb swelling, seroma, intestinal obstruction and wound infection. Limb swelling usually occurs but is rarely excessive and is easily controlled by elevation provided the profunda femoris vein is preserved and the popliteal vein is not harvested below the knee. Since the deep veins have been excised, lower limb DVT is unlikely. Wound and graft infection or anastomotic haemorrhage is similarly infrequent provided adequate antibiotic cover is used. [Q9: A, D, E, F, G]

Routine duplex surveillance of the aortofemoral vein grafts is wise as late graft stenosis due to intimal hyperplasia is common.38 [Q10: C]

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