The vascular surgeon, who has desperately needed a saphenous vein previously stripped for varicosities in a patient requiring urgent coronary artery bypass or other vascular reconstruction, is reluctant to remove this source of graft material for cosmetic reasons. Denton A. Cooley - Don C. Wukasch1Cooley DA, Wukasch DC: Techniques in Vascular Surgery, WB Saunders, Philadelphia, 1979, pp 229.Google Scholar Since the pioneer bypass interventions by Kunlin and Favaloro, autologous venous grafts have demonstrated their favorable behavior. In small vessels bypass, synthetic grafts have unacceptably low patency rates. A randomized, prospective multi-institutional study comparing greater saphenous vein (GSV) grafts to polytetrafluoroethylene (PTFE) revealed that saphenous vein had better patency rates.2Veith F.J. Gupta S.K. Ascer E. White-Flores S. Samson R.H. Scher L.A. et al.Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions.J Vasc Surg. 1986; 3: 104-114Google Scholar Four-year patency rates for PTFE grafts were only 12% when the outflow site was distal to the popliteal artery. The Best Endovascular vs. Best Surgical Therapy in Patients with Chronic Limb Threatening Ischemia (BEST-CLI) trial demonstrates the benefit of lower limb surgical revascularization with an adequate GSV, reducing significantly the incidence of major adverse limb events or death in the surgical group compared to endovascular group. 3Farber A. Menard M.T. Conte M.S. Kaufman J.A. Powell R.J. Choudhry N.K. et al.Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia.N Engl J Med. 2022; 387: 2305-2316Google Scholar Considering also the important role of saphenous vein bypass in the Global vascular guideline on the management of chronic limb-threatening ischemia, we recommend before ablation of the greater saphenous vein (GSV), to evaluate if its preservation is possible, maintaining it for future bypass.4Conte M.S. Bradbury A.W. Kolh P. White J.V. Dick F. Fitridge R. et al.Global vascular guideline on the management of chronic limb-threatening ischemia.J Vasc Surg. 2019; 69: 3S-125SGoogle Scholar In this article, we will highlight two relevant concepts, regarding the GSV potential use as a graft and its ablation. Concept 1.- The GSV of patients with VV may be an adequate conduit for arterial reconstruction: An important number of saphenous veins in patients with VV are apt for use in bypass. In fact, the first reversed vein graft used for a femoral popliteal bypass performed by Kunlin, in 1948, presented a varicose dilatation, and it remained patent until the patient died 28 years after. 5Melliere D. Desgrange P. Allaire E. Becquemin J.P. Long term results of venous bypass for lower extremity arteries with selective short segment prosthetic reinforcement of varicose dilatations.Ann Vasc Surg. 2007; 21: 45-49Google Scholar The presence of VV should not be a contraindication for the use of GSV as a conduit, especially in patients with no other available vein. Labropoulos studied the distribution and significance of varicosities in the saphenous trunk and defined them as 1) normal, 2) focal dilation (1.5-3 times the diameter), 3) varicosities, and 4) aneurysms (3 times the diameter). According to this definition, he found FD to be much more common than varicosities or aneurysms in the saphenous trunk. 6Labropoulos N. Kokkosis A. Spentzouris G. Gasparis A.P. Tassiopoulos A.K. The distribution and significance of varicosities in the saphenous trunks.J Vasc Surg. 2010; 51: 96-103Google Scholar A GSV with valve incompetence and a normal GSV trunk, FD or varicosities is not a contraindication for its use for bypass, and could be a good conduit for grafting, due to its physiological endothelial flow surface. Cohn, in an ultrasound morphological study before coronary bypass, assessed the GSV in patients with venous telangiectasia and varicose veins. The study showed that in most legs the GSV was normal and suitable for bypass, the varicosities were extra fascia and not directly located in the saphenous trunk and qualified as an appropriate graft.7Cohn J.D. Korver K.F. Selection of Saphenous Vein Conduit in Varicose Vein disease.Ann Thorac Surg. 2006; 81: 1269-1274Google Scholar Several techniques have been employed to maximize GSV use in the presence of FD, varicosities or aneurysms. Published studies on bypass surgery with such veins, show it is feasible, with similar outcomes to those without VV. 5Melliere D. Desgrange P. Allaire E. Becquemin J.P. Long term results of venous bypass for lower extremity arteries with selective short segment prosthetic reinforcement of varicose dilatations.Ann Vasc Surg. 2007; 21: 45-49Google Scholar,8Neufang A. Espinola-Klein C. Savvidis S. Schmiedt W. Poplawski A. Vahl C.F. et al.External polytetrafluoroethylene reinforcement of varicose autologous vein grafts in peripheral bypass surgery produces durable bypass function.J Vasc Surg. 2018; 67: 1778-1787Google Scholar Among the techniques to maximize autologous veins for infra-inguinal bypass is a technique using a mesh tube to provide external support. The external mesh stabilizes the vein and minimizes stress in the high-pressure arterial system to diminish the rate of stenosis and improve patency. Clinical series, although small, have shown that both PTFE and polyester prosthetic reinforcement of vein grafts with FD or aneurysms may be used with acceptable results.5Melliere D. Desgrange P. Allaire E. Becquemin J.P. Long term results of venous bypass for lower extremity arteries with selective short segment prosthetic reinforcement of varicose dilatations.Ann Vasc Surg. 2007; 21: 45-49Google Scholar,8Neufang A. Espinola-Klein C. Savvidis S. Schmiedt W. Poplawski A. Vahl C.F. et al.External polytetrafluoroethylene reinforcement of varicose autologous vein grafts in peripheral bypass surgery produces durable bypass function.J Vasc Surg. 2018; 67: 1778-1787Google Scholar Concept 2.- GSV ablation or removal is not mandatory when treating VV: Interventional treatment of varicose veins during the past century consisted mainly of surgical stripping or sclerotherapy; in the new millennium, thermal and non-thermal ablations are the more common procedures. Introducing duplex scanning for investigation of venous disease completely transformed diagnosis and understanding of VV. Duplex mapping brought several new anatomical and physiological concepts. Claude Franceschi in Paris, 1988, based in hemodynamic investigations with duplex scanning, developed and published "Ambulatory Conservative Hemodynamic Correction of Venous Insufficiency" (CHIVA) cure to treat venous hypertension, preserving the saphenous veins. Although further clinical studies are needed, a recent Meta-Analysis by Guo et al., concludes CHIVA seems to have superior clinical benefits on long-term efficacy for treating VV. 9Guo L. Huang R. Zhao D. Xu G. Liu H. Yang J. et al.Long-term efficacy of different procedures for treatment of varicose veins: a network meta-analysis.Medicine. 2019; 98e14495Google Scholar Paul Pittaluga described the "Ablation Sélective des Varices Sous Anesthésie Locale" ASVAL method, a procedure which spares the Saphenous Vein while treating VV. These are some examples of the methods available to treat VV and preserve the GSV. The authors of this article, in the light of available evidence and the great advantage of GSV preservation, invite vascular surgeons to consider first GSV sparing procedures and ablation only in cases without that option. GSV ablation is in many cases preventable, even when the terminal valve (saphenous femoral) is incompetent, the alternative procedures mentioned above may be considered and informed to the patient. This is especially important in patients with cardiovascular risk factors like diabetes mellitus or patients with cardiovascular or arterial conditions who are most prone to need a graft in the short or long term. SOS: Save Our Saphenous In his 2016 Presidential Address from the Society for Vascular Surgery, Peter Lawrence illustrates an alarming increment of, 4529% in saphenous vein ablations in the United States of America between 2006 and 2016. 10Lawrence P.F. "Better" (sometimes) in vascular disease management.J Vasc Surg. 2016; 63: 260-269Google Scholar He cites Russell Samson, call for a new SOS society, "Save Our Saphenous" to prevent unnecessary ablations of veins. The increasing incidence of VV, CVI, and the overuse of ablation make GSV venous grafts unavailable for bypass. Procedures that preserve the GSV for the treatment of CVI, should be considered and explained to the patient as an option and a must for patients with cardiovascular risk factors and arterial disease. Vascular societies and surgeons should consider educational campaigns, focusing on the preservation of the GSV, for much more needed procedures, in light of the increasing evidence of the importance of this vein as a potential graft.