A 54-year-old man comes to the physician for evaluation of exertional chest pain. He first noticed the pain a couple months ago when he was shoveling snow off his driveway and has since experienced several episodes while doing other strenuous tasks. He describes the pain as a heavy, crushing sensation and says it is relieved with rest. The patient undergoes coronary angiography and is found to have severe stenosis of the right coronary artery and left anterior descending and circumflex arteries. He is referred to a surgeon for coronary artery bypass grafting. During the procedure, a portion of his great saphenous vein is removed and grafted to one of the diseased coronary arteries to bypass its atherosclerotic narrowing. The vein used as a graft during this patient's procedure can be accessed at which of the following sites?

Question

A 54-year-old man comes to the physician for evaluation of exertional chest pain.  He first noticed the pain a couple months ago when he was shoveling snow off his driveway and has since experienced several episodes while doing other strenuous tasks.  He describes the pain as a heavy, crushing sensation and says it is relieved with rest.  The patient undergoes coronary angiography and is found to have severe stenosis of the right coronary artery and left anterior descending and circumflex arteries.  He is referred to a surgeon for coronary artery bypass grafting.  During the procedure, a portion of his great saphenous vein is removed and grafted to one of the diseased coronary arteries to bypass its atherosclerotic narrowing.  The vein used as a graft during this patient's procedure can be accessed at which of the following sites?

Quizplus · Accepted Answer

11ec160b_3555_0c05_9249_0de105be9c52_MD0001_00 When the left anterior descending artery (LAD) alone is occluded by an atherosclerotic plaque, the left internal mammary (thoracic) artery is the preferred vessel for bypass grafting due to superior patency rates. However, when multiple coronary arteries or vessels other than the LAD require revascularization, great saphenous vein grafts are routinely used. The great saphenous vein is located superficially in the leg and is the longest vein in the body. It courses superiorly from the medial foot, anterior to the medial malleolus, and up the medial aspect of the leg and thigh. In the proximal anterior thigh, 3-4 centimeters inferolateral to the pubic tubercle, the great saphenous vein dives deep through the cribriform fascia of the saphenous opening to join the femoral vein. Surgeons access the great saphenous vein in the medial leg or, less commonly, near its point of termination in the femoral triangle of the upper thigh. The femoral triangle is bordered by the inguinal ligament superiorly, sartorius muscle laterally, and adductor longus muscle medially. (Choice A) The popliteal artery and vein course centrally through the popliteal fossa together with the tibial nerve. Common medical problems that occur in the popliteal fossa include popliteal artery aneurysms, which account for the majority of peripheral artery aneurysms, and synovial (Baker's) cysts, which are commonly associated with arthritis. (Choice B) No major vessels are located immediately inferior to the anterior superior iliac spine (ASIS). The ASIS serves as the superior attachment of the inguinal ligament, and a penetrating injury to the region below the ASIS could damage the lateral cutaneous nerve of the thigh. (Choice D) The deep circumflex iliac vessels course parallel and just superior to the inguinal ligament. The superficial and inferior epigastric veins course above the midportion of the inguinal ligament. (Choice E) The small saphenous vein can be found at the lateral aspect of the foot. This vein courses posteriorly to drain into the popliteal vein. Educational objective: The great saphenous vein is a superficial vein of the leg that originates on the medial side of the foot, courses anterior to the medial malleolus, and then travels up the medial aspect of the leg and thigh. It drains into the femoral vein within the region of the femoral triangle, a few centimeters inferolateral to the pubic tubercle.

A 54-Year-Old Man Comes to the Physician for Evaluation of Exertional