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Distal Peroneal Bypass for Limb Salvage: A Case Demonstrating a Right Femoral to Peroneal Bypass Using a Lateral Approach with Fibulectomy
Natalia Ashely Cavagnaro, Eric Trestman, Hunter Ray
HCA Healthcare Kingwood/University of Houston, Kingwood, TX

OBJECTIVES:The efficacy of using the distal peroneal artery (PA) as an outflow for bypass has been established, however its use is often deterred by a number of anatomic considerations and their superimposed technical challenges. In patients with limb-threatening ischemia who lack suitable tibial vessels, but have adequate PA outflow, a peroneal bypass is the preferred method of revascularization for limb salvage. Here we demonstrate the technique for lateral approach to the distal peroneal artery with fibular resection.
METHODS:We present a case of chronic limb threatening ischemia (CLTI) in a patient with prior bypass, and multiple failed attempts with endovascular treatment, who underwent a distal popliteal bypass for limb salvage. Here we demonstrate the technique used for successful revascularization with a right common femoral to peroneal bypass using a lateral approach with fibulectomy RESULTS:he procedure was completed without complications and with evidence of successful revascularization. Lateral exposure of the PA was achieved via fibulectomy involving meticulous periosteal dissection carried out circumferentially, to avoid injury to the deep peroneal structures, and prevent bleeding from perforator branches. The demonstrated technique allows for division and subsequent resection of the fibular segment while protecting the structures immediately posterior in the fibular bed. The lateral exposure highlights important technical considerations regarding patient selection and chosen approach. Finally, intraoperative arteriography was used to confirm adequate inflown and runoff, as well as to stress the significance of inadequate flow to the pedal arch as a predictor of graft failure. Prior to wound closure, an intact pedal arch was visualized, and the foot confirmed to have brisk flow. CONCLUSIONS:The use of the distal PA as an outflow for bypass is deterred by several factors. It only allows for indirect revascularization of the plantar arch, it is remote to inflow vessels, and peroneal exposure itself can be technically challenging. However, it is important to remember this approach as it is the preferred method of revascularization for patients with CLTI who have suitable peroneal outflow and are obese or have undergone previous bypass. The surgical approach presented is feasible as a limb-salvaging intervention. This technique should be considered in selected cases in which the benefits outweigh those of limb amputation.
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