Recent trends in bypass surgery performed in patients with critical limb ischemia

Recently, many candidates for infrainguinal bypass surgery have been patients with diabetes and tended to have ischemic tissue loss or gangrene. In the management of these patients, many technical strategies are required to obtain a good outcome after bypass surgery. The predisposing region of diabetic atherosclerosis is typically the tibial artery trunk and crural arteries. Inframalleolar bypass is ideal to supply the maximum blood flow to the foot. For this purpose, in situ bypass surgery has been the first choice since the advent of the LeMaitre valve cutter. Combined inflow percutaneous transluminal angioplasty and distal bypass are indicated for patients with a TASC A lesion in the iliac artery or superficial femoral artery. This procedure is advantageous especially for patients with end-stage renal disease (ESRD) to decrease the surgical invasiveness and to preserve the autogenous vein. Patients with ESRD usually have severe calcification of the intrinsic foot artery and sometimes a dual bypass to the pedal arteries are useful to expedite healing. Meticulous topical debridement after bypass surgery is also essential for accelerating the healing process. In this situation, negative-pressure wound drainage is currently used worldwide. Free tissue transfer, which is often combined with bypass, is another armament to salvage a severely gangrenous foot.