Where does the pedal bypass stand today?

For decades autologous bypass surgery to arteries of the foot has been an option for revascularization in critical limb ischemia, particularly in diabetic patients. The 1‑year patency rates of 50–80 % and limb salvage rates of more than 80 % have proven the effectiveness of this type of peripheral vascular reconstruction; however, the growing importance of endovascular management of stenosis and occlusions of crural arteries has substantially lowered the role of pedal bypass surgery. Less invasiveness with reduced morbidity and mortality render percutaneous angioplasty techniques more attractive compared to open surgery, but recent data suggest that primary revascularization by bypass surgery (“straight line to the foot”) may provide a more effective and sustained healing of pedal wounds; however, adherence to the angiosome concept probably plays a minor role in comparison to endovascular treatment. Diagnostic measures, such as duplex ultrasound and contrast-enhanced magnetic resonance imaging may serve as important complimentary methods for detection of suitable pedal target vessels. Apart from the great saphenous vein alternative autologous grafts, such as arm veins and the small saphenous vein can be used. Long-term surveillance of pedal bypasses has widely been recommended. More studies are warranted for a better understanding of the future role of this type of bypass surgery in critical limb ischemia. © 2018, Springer Medizin Verlag GmbH, ein Teil von Springer Nature.