Infrapopliteal arterial reconstruction in the severely ischemic lower extremity. A comparison of long-term results of peroneal and tibial bypasses.

The feasibility of limb salvage with bypasses to the infrapopliteal arterial tree has been established. In this review, our experience with bypasses to the peroneal artery is compared with that to the tibial arteries. Autogenous saphenous veins were employed in 164 limb salvage arterial revascularizations because of gangrene, ischemic ulceration, or rest pain. These were retrospectively analyzed by the life-table method. Femorotibial (137) or femoroperoneal (27) bypasses were performed on the basis of adequate preoperative arteriograms demonstrating the distal arterial tree, but with no popliteal runoff. Overall operative mortality was 6.1%. Initial limb salvage was 71.2 +/- 3.9% following femorotibial bypass and 51.9 +/- 9.6% after femoroperoneal bypass. Five and seven year cumulative limb salvage rates for femorotibial bypass were 48.5 +/5.2% and 43.4 +/- 6.7%; those for femoroperoneal were equivalent at 38.2 +/- 9.9%. Since long-term limb salvage can be realized in a large number of patients by revascularization of the distal arterial tree, primary amputation is seldom indicated. Operative approach to the ischemic limb must be based on a thorough preoperative arteriogram which demonstrates contrast within vessels down to the distal foot. This is almost always seen and arterial reconstruction is usually feasible. Therefore, limb salvage should be attempted in lieu of primary amputation whether tibial or peroneal arteries are visualized on preoperative arteriogram.     

Distal polytetrafluoroethylene bypasses in patients older than 75 years

HYPOTHESIS: Polytetrafluoroethylene (PTFE) alone is justified for infrapopliteal arterial grafting in elderly patients with critical ischemia of the lower limbs who lack a suitable, autogenous saphenous vein. DESIGN: A consecutive sample clinical study with a mean follow-up of 16 months. SETTING: The surgical department of an academic tertiary care center and an affiliated secondary care center. PATIENTS: Thirty-one patients older than 75 years with critical ischemia of the lower limbs received 34 PTFE bypass grafts to the infrapopliteal arteries: 12 patients to the anterior tibial, 8 to the peroneal, 8 to the posterior tibial, and 2 to the dorsalis pedis artery. MAIN OUTCOME MEASURES: Cumulative survival, primary graft patency, and limb salvage rates expressed by standard life-table analysis. RESULTS: Operative mortality rate was 3%. Cumulative survival rate was 80% at 2 years (SE, 9.2%) and 43% at 3 years (SE, 11.4%). Cumulative primary patency rate was 67% at 2 years (SE 9.1%), and 61% at 3 years (SE, 12.7%). Cumulative limb salvage rate was 77% at 2 years (SE, 8.7%) and 70% at 3 years (SE, 12.8%). CONCLUSION: Polytetrafluoroethylene alone is justified as graft material for infrapopliteal bypass grafts in elderly patients with critical ischemia of the lower limbs and without a suitable autogenous saphenous vein.     

Distal bypass for limb salvage in very elderly patients

During the last 3 1/2 years, 40 bypasses to a tibial or peroneal artery (distal bypass) were performed for severe leg ischemia in 34 patients who were 80 years of age or older (range, 80-91; mean, 85). The operative mortality rate was 5 per cent. Cumulative life-table limb salvage rates for the 40 extremities were 91 per cent at 1 year and 81 per cent at 3 years. Graft patency rates at 1 and 3 years were 88 per cent and 56 per cent, respectively. Survival rates for the 36 patients were 91 per cent and 58 per cent at 1 and 3 years, respectively. Among 134 patients younger than 80 years who underwent 142 distal bypasses during the same 3 1/2-year period, no operative deaths occurred. In this younger group, cumulative life-table rates at 1 and 3 years were 89 per cent and 89 per cent, respectively, for limb salvage, 86 per cent and 85 per cent, respectively, for graft patency, and 93 per cent and 78 per cent, respectively, for survival. There were no statistically significant differences in these figures for the younger group when compared with corresponding figures for the older group. Among the 36 very elderly patients who underwent distal bypass for limb salvage, 24 patients (67%) with 25 revascularized limbs are alive and have a salvaged, functional extremity after follow-up as long as 41 months (mean, 21 months). These results suggest that an aggressive approach using distal bypass is warranted for limb salvage in very elderly patients.     

Distal tibial artery thrombectomy in acute limb ischemia

During the past two years, in cases of infrapopliteal embolic occlusion not retrievable through the femoral approach, we have used distal tibial thrombectomy in preference to a direct approach via the popliteal artery. Distal tibial thrombectomy was done in seven extremities in six patients with excellent results. Only one extremity required subsequent amputation. There were no mortalities. This represents a limb salvage rate of 85%.     

Increased limb salvage with intraoperative and postoperative ankle level urokinase infusion in acute lower extremity ischemia.

Over a 30-month period (May 1988 to November 1990) 143 acutely ischemic lower extremities (126 patients) were treated with an aggressive surgical approach that included ankle level tibial-peroneal artery thromboembolectomy. Twelve lower extremities in 10 patients that remained ischemic were further treated with adjuvant ankle level urokinase infusion. Sixteen ankle level arteries in 12 extremities were infused with an intraoperative bolus (1 to 2) of urokinase (50,000 to 100,000 units). Continuous postoperative urokinase (25,000 to 50,000 units per catheter per hour x 1 to 5 days) was infused through ankle level arteriotomies in 10 extremities (14 arteries) that did not improve with the initial intraoperative bolus. Concomitant bypass grafting was necessary in four extremities. With adequate inflow established, adjuvant ankle level urokinase salvaged all 12 extremities. The mean increase in ankle/brachial pressure index was 0.84. During continuous postoperative urokinase infusion, lower extremity bleeding requiring blood transfusion occurred in four patients (50%). No deaths occurred in the operative period. Although rhabdomyolysis occurred in 90% of patients, no patients had renal insufficiency. The addition of ankle level urokinase delivery increased the potential limb salvage from 90% of the entire 143 extremities treated during this period to an actual limb salvage of 98%. A mean follow up of 13 months (6 to 36 months) identified one late amputation. Despite the demanding postoperative management required in these patients and the frequent need for early reoperation, the limb salvage obtained justifies this aggressive adjuvant technique in the management of the acutely ischemic lower extremity.     

急性肢体动脉栓塞26例诊断与治疗

目的 探讨急性肢体动脉栓塞的诊断、治疗与预后。方法回顾性分析2002年5月至2005年7月大连大学附属中山医院血管外科收治的26例急性肢体动脉栓塞病人的病例资料，26例均急诊行动脉切开Fogarty导管取栓并配合药物治疗。结果无死亡病例，26条肢体均获保存，术后肢体变暖，24例病人肢体远端动脉搏动恢复。2例肢体远端动脉搏动未恢复。结论早期诊断、及时动脉切开Fogarty导管取栓，是保存缺血肢体的关键因素。     

Pedal branch arterial bypass for limb salvage

In patients with critical lower extremity ischemia and occlusion of the distal tibial and pedal arteries bypasses to pedal artery branches may offer the only alternative to primary amputation. The results of 22 pedal branch arterial bypasses are reported, and a review of the literature is offered. The charts of 22 patients undergoing pedal branch arterial bypass during a 12-year period were retrospectively reviewed. The results of six additional reports of this technique were also evaluated. In the present series the cumulative primary graft patency rate was 72 per cent after 2 years. The cumulative limb salvage rate during this interval was 82 per cent. Similar graft patency and limb salvage rates were obtained with the approximately 200 other bypasses of this nature as reported in six other series. Pedal branch arterial bypass offers limb salvage results that are comparable to perimalleolar and pedal artery bypasses. In patients with critical limb ischemia and occlusion of distal tibial and pedal arteries, pedal artery branches should be sought as potential outflow sites. Bypasses to these arteries result in good long-term limb salvage, improved survival, and good functional ability for amputation. Pedal artery branch bypasses are a superior alternative to primary amputation.     

In situ saphenous vein for lower extremity revascularization.

BACKGROUND. During a 6-year period, 349 in situ saphenous vein bypass grafts were performed for limb salvage by three surgeons. METHODS. Outflow anastomoses were constructed to the infrageniculate popliteal (25%), posterior tibial (20%), peroneal (20%), anterior tibial (19%), and dorsal pedal arteries (7%). Mean patient age was 70 1/2 years. RESULTS. The 30-day mortality rate was 3.2%, and 19% died during the ensuing 68-month interval. At 1, 24, and 60 months primary graft patency was 89%, 77%, and 74%, secondary graft patency was 91%, 80%, and 78%, and cumulative limb survival was 94%, 88%, and 84%, respectively. Cumulative patency rates at 60 months depending on outflow site were as follows: popliteal (85%), anterior tibial (80%), posterior tibial (70%), dorsal pedal (68%), and peroneal (60%). Patency at the peroneal position was significantly inferior to that of other infrapopliteal sites combined (p less than 0.05). Cumulative limb survival at 60 months, according to outflow site, was as follows: popliteal (95%), anterior tibial (85%), posterior tibial (78%), dorsal pedal (73%), and peroneal (67%). There was no significant difference in limb salvage among infrapopliteal outflow sites. However, patency rates and limb salvage were significantly better for the popliteal outflow site than the infrapopliteal outflow sites (p less than 0.01). CONCLUSIONS. (1) A 5-year graft patency rate of 78% and a limb salvage rate of 84% are achievable, (2) peroneal bypass is associated with a lower rate for graft patency but not limb salvage, and (3) popliteal bypass has the best graft patency and limb salvage rates.     

Duplex-guided balloon angioplasty and subintimal dissection of infrapopliteal arteries: early results with a new approach to avoid radiation exposure and contrast material

OBJECTIVE: Balloon angioplasties of stenotic or occluded infrapopliteal arteries may be helpful in selected high-risk patients threatened with limb loss. Thus far, these procedures have demanded fluoroscopy and the injection of potentially nephrotoxic contrast material. Herein, we proposed a new alternative to avoid the harmful effects of radiation exposure and the risk of acute renal failure. METHODS: Over the last 16 months, 30 patients (57% male) aged 74 +/- 9 years (mean +/- SD) had a total of 52 attempted balloon angioplasties of the infrapopliteal arteries in 32 limbs under duplex guidance. Indications for the procedure were critical ischemia in 20 limbs (63%), including rest pain, ischemic ulcers, and gangrene in 4 (13%), 10 (31%), and 6 (19%) limbs, respectively. Severe disabling claudication was an indication in the remaining 12 limbs (37%). All patients had concomitantly performed balloon angioplasties of the superficial femoral and popliteal arteries (28 cases) or the popliteal artery alone (4 cases). Balloon angioplasty of the infrapopliteal arteries was performed as an adjunct to improve runoff. Hypertension, diabetes, renal insufficiency, smoking, and coronary artery disease were present in 77%, 73%, 50%, 47%, and 37% of cases, respectively. There were 42 cases (81%) with infrapopliteal arterial stenoses (25 tibioperoneal trunks, 9 peroneal arteries, 4 anterior tibial arteries, and 4 posterior tibial arteries) in 26 limbs. The remaining 10 cases (19%) had infrapopliteal arterial occlusions (4 tibioperoneal trunks, 5 peroneal arteries, and 1 anterior tibial artery) in 6 limbs. All these cases were combined with more proximal endovascular procedures (21 femoropopliteal stenoses and 11 femoropopliteal occlusions). All patients had preprocedure duplex arterial mapping and ankle/brachial index (ABI) measurement. Local anesthesia with light sedation was used in all cases. The common femoral artery was cannulated under direct duplex visualization. Still under duplex guidance, a guidewire was directed into the proximal superficial femoral artery and distally, beyond the infrapopliteal diseased segment. The diseased segment was then balloon-dilated. Balloon diameter and length were chosen according to the arterial measurements obtained by duplex guidance. Completion duplex examinations were performed and postprocedure ABIs were obtained in all cases. RESULTS: Although the overall technical success was 94% (49/52 cases), it was 95% for those with stenoses (40/42 cases) and 90% for those with occlusions (9/10 cases; P < .5). Intraoperative thrombosis occurred in three infrapopliteal cases (two tibioperoneal trunks and one peroneal artery) and in one popliteal artery. All four cases were successfully managed with intra-arterial infusion of thrombolytic agents under duplex guidance. Overall, the preprocedure and postprocedure ABIs ranged from 0.4 to 0.8 (mean +/- SD, 0.58 +/- 0.15) and 0.7 to 1.1 (mean +/- SD, 0.9 +/- 0.16), respectively (P < .0001). Twenty-two (88%) of 25 patients experienced a significant (> 0.15) postoperative ABI increase. Overall 30-day survival and limb salvage rates were 100%. CONCLUSIONS: The proposed technique eliminates the need for radiation exposure and the use of contrast material, and it seems to be an effective alternative approach for the treatment of infrapopliteal occlusive disease. Additional advantages include accurate selection of the proper size of balloon and confirmation of the adequacy of the technique by hemodynamic and imaging parameters.     

Early surgical results on acute arterial occlusion of the extremities

Although the earliest possible embolectomy is still correlated with best rates of limb salvage, we consider, as do most other authors, that the only critical criterion for operability must be the viability of the ischemic limb. Even in the presence of gangrene of the foot relief of arterial occlusion is recommended in order to secure a more distal amputation. Arterial embolectomy seems to be a simple surgical procedure; however, in the presence of atherosclerotic arteries or in the cases of acute arterial thrombosis the operative procedure needs considerable experience in vascular surgical techniques to secure a successful outcome. Finally, the prevention and early treatment of the revascularization syndrome together with appropriate cardiopulmonary management in a strict intensive-care unit can improve the mortality significantly in cases of acute arterial occlusion of the extremities.     

Influence of transmetatarsal amputation in patients requiring lower extremity distal revascularization

When a transmetatarsal amputation (TMA) is required, successful long-term limb salvage is questioned. We evaluated the influence of TMA on limb salvage in patients undergoing lower extremity revascularization. Patients who had distal bypasses extending to the infrapopliteal arterial tree and adjunctive TMA were retrospectively reviewed. Limb salvage was determined with life-table analysis. Twenty-four patients (29 limbs) were evaluated: 15 male and 9 female. Average age was 64.2 years old. Gangrene was the indication for bypass and TMA in 25 (86.2%) patients. Seven limbs were lost to follow-up. Nine of the remaining 22 limbs required below-knee (8) or above-knee (1) amputations, seven limbs within the first 3 months. In the group of patients who had major amputations within the first 3 months, graft thrombosis was the cause of leg amputation in six (85.7%) cases. No significant predictors of early major amputation were identified. Limb salvage was 62 per cent at 1 year in the TMA group. In comparison, among historical controls requiring distal revascularization and no adjunctive toe or foot amputations, limb salvage was 76.5 per cent (P = NS). Long-term limb salvage is dependent on successful lower extremity revascularization. Requirement for TMA should not influence the decision for limb salvage.     

杂交技术治疗复杂下肢动脉硬化闭塞症疗效分析

目的:探讨采用杂交技术治疗复杂下肢多节段动脉硬化闭塞症的临床疗效。方法:分析2014年3月—2014年9月行杂交技术治疗的30例(30条患肢)复杂下肢动脉硬化闭塞症患资料。30例患者病变部位累及主-髂动脉、股-腘动脉、股深动脉以及膝下动脉;均行血管腔内修复术,20例行动脉内膜剥脱术,10例行动脉取栓术,8例加行股深动脉成形术。结果:30例杂交手术均获得成功,技术成功率100%,围手术期并发症发生率30%(9/30)。临床成功率为96.67%,术后平均踝肱指数较术前提高了0.37±0.19。术后6、12个月一期通畅率分别为90%、73%,12个月救肢率为97.67%。结论:杂交技术治疗复杂下肢动脉硬化闭塞症具有较高的短期通畅率和救肢率。     

Peroneal artery bypass: A reappraisal of its value in limb salvage

In general the surgical literature has expressed pessimism about the value of bypass to the peroneal artery for limb salvage. The combination of greater technical difficulty, low patency rates, and hemodynamic failures have led to the establishment of this prejudice. In a review of 284 arteriograms in limbs with infrapopliteal arterial occlusion, the peroneal artery was the least diseased in 40% and was the only available vessel in 37% of instances. One hundred fifty-two peroneal bypasses have been performed in a 7-year period, 116 by the in situ method, 23 with excised vein, and 13 by nonautogenous conduits. During the same period 125 anterior tibial and 114 posterior tibial bypasses were also done. The mean preoperative ankle/brachial indices were 0.27 for peroneal, 0.25 for anterior tibial, and 0.29 for posterior tibial bypasses. These were converted to mean postoperative indices of 0.84, 0.86, and 0.92, respectively. Corresponding transmetatarsal/brachial indices were 0.72, 0.75, and 0.90. Rest pain was relieved in all these patients, and in 94 patients with tissue loss, there were 11 major amputations, nine healed forefoot amputations, and 20 healed digital ray amputations. Hemodynamic failures were two in the peroneal, two in the anterior tibial, and three in the posterior tibial group with one perioperative amputation in each. The cumulative limb salvage rate at 3 years for the peroneal group was 81%. This experience has shown that the patency and limb salvage rates obtained are comparable to those for the anterior and posterior tibial arteries and that hemodynamic failure is an uncommon occurrence. The influence of the presence of the pedal arch on both patency and limb salvage also shows that although poorer results are obtained when the pedal arch is absent, this should not be a deterrent to performing a peroneal bypass. (J VASC SURG 1984;1:809-816.)     

膝下动脉闭塞的腔内治疗

目的 总结40例膝下动脉闭塞腔内治疗的疗效.方法 2006年11月至2007年12月期间40例下肢膝下动脉闭寨患者41条患肢行44次腔内治疗,平均年龄(76±6)岁,治疗前踝/肱指数(ankle brachial index,ABI)足背动脉0.39±0.20,胫后动脉0.39±0.23,严重下肢缺血(criticallimb ischemia,CLI)占80.49%(33/41).结果 治疗后ABI足背动脉提高了 0.43±0.22(P<0.01),胫后动脉提高了0.43±0.25(P<0.01).35例36条肢体获随访,平均随访(6±3)个月,Fontaine Ⅰ级与Fontaine Ⅱ A级肢体共计28条,占77.78%,CLI降至19.44%(7/36),显著低于治疗前(P<0.01),随访时ABI足背动脉0.63±0.22,胫后动脉0.56±0.22,与治疗前相比差异均有统计学意义.治疗后及随访时患肢的足背动脉与胫后动脉ABI比较差异无统计学意义.全组围手术期截肢率为0,围手术期死亡率2.5%,总死亡率15%,保肢率100%.结论 膝下动脉腔内治疗后疗效和平均随访6个月的疗效均令人满意;膝下动脉腔内治疗可以成为膝下动脉闭塞治疗的首选方法.     

大隐静脉原位转流术重建下肢血液循环

目的:评价大隐静脉原位转流术治疗下肢动脉硬化闭塞症的疗效.方法:运用自制瓣膜切除器开展大隐静脉原位转流术治疗下肢动脉硬化闭塞症38例共40例肢体.患者术前踝肱指数(ABI)为0-0.58(平均0.29),均经动脉造影证实.术后移植物均可扪及搏动,有28条肢体足背或胫后动脉搏动恢复,17例同时行输入输出道动脉重建术,溃疡清创术6例,4例于术后3天内出现移植物搏动消失,行第2次重建术,结果:ABI平均值同术前0.29上升至0.84,严惩缺血肢体挽救率为100%,经寿命表统计分析,1-5年的血管累积通畅率分别为92%,87%,82%,72%和65%,结论:大隐静脉原位转流术是治疗下肢动脉硬化闭塞症的理想方法之一,同时行输入功输出道动脉重建术,对保证移植血管的通畅有着重要的意义.     

Acute arterial occlusion of the extremities. Rate of success following simple embolectomy and following combined procedures

Acute arterial obstruction of the extremities represents the most common emergency in vascular surgery. Diagnosis is based on the typical history and clinical symptoms. Emboli in vessels without atherosclerotic changes can be removed by simple embolectomy. In atherosclerotic arteries or in cases of acute thrombotic occlusion preoperative angiography is recommended in order to perform extensive reconstructive procedures. 400 arterial reconstructions for acute obstruction of the extremities were analysed. 46 operations were done in the upper extremities. In the majority of the cases simple embolectomy was successful. Limb salvage was 100% although one embolectomy and one bypass procedure failed to restore full revascularization. Complication and mortality rate was low. 354 lower limbs were operated. 274 extremities could be saved (77.4%). Among 80 poor results 48 major amputations had to be done (13.5%). Perioperative mortality was 12.4%. Death was mainly attributed to myocardial infarction.     

腔内介入治疗膝下动脉缺血性疾病

目的 回顾性分析血管腔内介入治疗膝下动脉缺血性疾病的疗效,初步总结其技术要点、主要并发症防治与应用价值.方法 对2004年11月至2007年7月期间收治的60例(65条肢体)膝下动脉缺血性疾病的患者行膝下病变段动脉球囊扩张(percutaneous transluminal angioplasty,PTA)和/或支架植入(stenting)治疗,观察症状的改善,踝肱指数(ankle/brachial index,ABI)的变化,保肢率以及近期通畅率.结果 60例患者(65条肢体)中,技术成功51例,成功率83.3%;临床成功53例,成功率88.3%.症状完全缓解40例(66.7%),部分缓解13例(21.7%),无改善7例(11.6%);ABI从术前0.40±0.18增加到术后0.91±0.22,两者差异有统计学意义(P＜0.01).2例膝下截肢,4例足趾截趾,出院时保肢率为91%.随访54例,随访时间10 d至30个月,平均(14.5±1.2)个月.2例膝上截肢,2例膝下截肢,2例足趾截趾,保肢率88.9%(48例/54例);症状复发5例,复发率9.2%,血管再闭塞或再狭窄10例,通畅率81.5%,1年累积通畅率为57.3%.结论 腔内介入治疗膝下动脉缺血性疾病安全、可行,近期疗效确切,是该类疾病重要的治疗选择.     

Early results of low dose intra-arterial streptokinase therapy in acute and subacute lower limb arterial ischaemia

Thirty-two patients with acute and subacute limb-threatening peripheral arterial ischaemia were treated with low dose intra-arterial streptokinase infusions. The mean duration of infusion was 38 h. Six patients developed pericatheter thrombosis and two had distal embolization of fragments of thrombus but in all cases these responded to repositioning the catheter and continuing the infusion. Five patients developed groin haematomata and in three of these there was evidence of a systemic fibrinolytic effect from the streptokinase with plasma fibrinogen reduced below 1 g/l. The most serious complication was perforation of the popliteal and tibial arteries which occurred on two occasions and required cessation of the infusion. Twenty-two patients (69 per cent) achieved limb salvage, eight (25 per cent) suffered a major amputation and two (6 per cent) died. The outcome was not related to the site, nature or duration of the arterial occlusion but patients with loss of sensation or paralysis of the affected limb were significantly less likely to obtain limb salvage (P = 0.001). For occlusions greater than 30 cm in length a new technique was used where the thrombus was lysed from distal to proximal in short lengths by gradual catheter withdrawal. This was successful in five out of six cases. Low dose intra-arterial streptokinase has been confirmed as an effective, relatively safe method of treatment in recent arterial ischaemia and can be recommended in situations where the results of surgery may not be favourable. In particular, patients with arterial thromboses and no distal run-off, distal and late arterial emboli, thrombosed popliteal aneurysms and patients after a failed embolectomy, have all been shown to respond to thrombolytic therapy with intra-arterial streptokinase.     

Reversed vein bypass to infrapopliteal arteries. Modern results are superior to or equivalent to in-situ bypass for patency and for vein utilization.

In recent years many reports have attributed improved patency and improved vein utilization with lower extremity arterial bypass to infrapopliteal arteries to the use of the in-situ vein graft technique (ISVB). This report describes 110 reversed vein bypasses (RVB) to infrapopliteal arteries performed from 1980-1986. Thirty-three per cent of these patients did not have an intact ipsilateral greater saphenous vein. One hundred per cent of patients had autogenous RVB performed using a variety of techniques, including vein splicing, use of arm veins, lesser saphenous veins, branch veins, and use of graft origins distal to the common femoral artery. The life table patency figures for these grafts are 90%, 85%, and 85% at 1 year, 3 years, and 5 years, respectively. The life table limb salvage at 5 years is 93%. These figures for patency, vein utilization, and limb salvage for modern RVB to infrapopliteal arteries are clearly equal to or superior to any reported figures for ISVB. Results for RVB are greatly improved when compared with historic controls, as are results for ISVB. There is no evidence to date demonstrating superiority of one technique versus another.     

Femoroperoneal bypass: evaluation of potential for revascularization of the severely ischemic lower extremity.

In 79 patients in whom distal small vessel bypass with autogenous vein was used for revascularization because of gangrene, gangrenous ulceration or rest pain, 14 had femoroperoneal bypasses. Femorotibial or femoroperoneal bypasses were performed in those patients in whom no popliteal runoff was present on pre-operative arteriogram. Femoroperoneal bypass was performed in preference to primary amputation in each case. Nine of 14 (64.3%) of femoroperoneal bypasses were functional whereas 57 of 79 (72.2%) of total distal bypasses to small vessels were functional. Salvage of severely ischemic lower extremities was achieved in 5 of 14 (35.7%) patients after femoroperoneal bypass and in 46 of 65 (70.8%) patients after bypass to anterior tibial or posterior tibial arteries. Graft patency without limb salvage occurred in 4 of 9 (44.4%) patients with patent femoroperoneal bypasses and in only 2 of 48 (4.2%) of patients with femorotibial bypass. Although limb salvage rate is considerably less with femoroperoneal than femorotibial or femoropopliteal bypass, attempted limb revascularization by peroneal bypasses is preferable to primary amputation in patients with rest pain, gangrenous ulceration or gangrene.