Knacks and Pitfalls of Surgical Bypass for Critical Limb Ischemia

Abstract

Arterial reconstruction is sine qua non to reach the goals of treatment for critical limb ischemia (CLI). Surgical bypass is still the first option for patients with long life expectancy or with a large tissue loss, even in the era of endovascular treatment. It goes without saying that the key to success for treatment for CLI is in a preoperative deliberate plan. Therapeutic strategy including surgery should be determined with imaging examinations and clinical symptoms. The proximal anastomosis is selected in the artery with good inflow and the distal anastomosis is selected in the less diseased artery with good runoff vessels. However, the final decision regarding the site of distal anastomosis should be made after intraoperative angiography. Availability of saphenous vein for bypass conduit should be evaluated with ultrasound or computed tomography and it should be marked preoperatively for easy harvest. Optimal bypass route as well as bypass method is also decided preoperatively. Since it does not always proceed as planned, alternative plans should be prepared. The author herein described the knacks and pitfalls in the operative procedures of infrainguinal bypass with a non-reversed vein graft, which has been most often performed in our team.