Useful tips and tricks for successful crural and pedal bypass surgery

The strategy for successful placement of a distal bypass should already be defined during the first patient contact after estimation of the general operative risk. A prerequisite is an adequate imaging that enables a reliable assessment of the arterial inflow to the leg and the planning of the site of the anastomosis. A completely autologous reconstruction should fundamentally always be the primary goal of all peripheral bypass operations, before the prosthetic material is used. An intact ipsilateral or contralateral greater saphenous vein is considered to be the ideal graft but is not always available in the necessary length and quality. For this reason, arm veins and lesser saphenous vein should always be included in the planning of a completely autologous bypass. Mastering the technique of venous end-to-end anastomosis is essential to enable the construction of autologous spliced vein grafts. The localization and configuration of the proximal anastomosis are selected according to the individual anatomy. The possibility to use the profunda femoris artery for the origin of the bypass should always be borne in mind. For the distal anastomosis, the best-preserved distal vessel with a direct outflow to the foot should be chosen whenever possible. A careful and subtle surgical technique with limited exposure of the crural and pedal vessels and avoidance of clamping is crucial. A simple tourniquet technique can enable an anastomosis of severely calcified vessels in a bloodless field. Prosthetic material should only be used for crural and pedal bypass surgery if autologous veins in the necessary length are unavailable. In this case, the creation of the distal anastomosis with an autologous vein cuff or patch should be preferred. In selected cases a sequential composite bypass graft with autologous veins can be a good solution. Prosthetic grafts should be preferentially placed in a subfascial position. Autologous vein grafts can also be placed in the subcutaneous tissue. Each crural or pedal bypass reconstruction should be regarded as an individualized construction.