A distal bypass or an arterial bypass on a tibial or pedal artery is often needed especially in diabetic patients with critical lower limb ischemia. Generally it is considered a bothersome procedure, where someone needs to try too much, spend a long time with questionable results. Is it so? Well, partly yes, but I feel that it almost always worth a try. Let’s see how to do it.

  • Step 1: Target vessel exposure

Start from the recipient site. Based on the preoperative angiogram you must have already a target vessel for the revascularization. Whether it is a tibial or a pedal artery, you need to dissect it first. Just remember, that you do not need to spend too much effort on that. Just a small part of the artery, of about 5cm or less in length is adequate. Gently squeeze it with a pair of Debakey forceps. Does it feel soft and compressible. This is it. It almost always is a great target vessel. Is it hard and incompressible. Try to find a soft part. If  not do not reject the site. Grab an 11 blade and make a cut along its anterior surface, and get into the lumen. Is there back-bleeding. This is good. This is still a target. Is there no lumen? It’s time to abandon the case and try for another site or send the patient back in the ward. 

Something to remember: avoid to any cost to do an endarterectomy on the distal target vessel. Either you make the anastomosis as it is or abandon. 

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