The distal anastomotic site has no impact on the results of femorodistal reconstructions. As a rule, a tibial artery is used if its lumen runs into the foot without obstruction, though by-passes to disadvantaged outflow segments may be performed successfully. Generally, the peroneal artery is used only if it communicates with foot arteries. Although the ability of peroneal revascularization to perfuse the foot sufficiently has been criticized, many studies have demonstrated equivalent patencies of peroneal and other tibial or pedal by-pass grafts [16, 30, 63, 71, 79, 84]. The major determinant of by-pass patency is the status of the run-off bed. The integrity of the plantar arch is a reliable prognostic indicator of the primary patency rate of the grafts . However, neither the absence of a plantar arch nor vascular calcification is considered a contraindication to a reconstruction.
By-pass to the distal ankle and foot arteries (Fig. 7.2.4), the so-called para- or inframalleolar by-pass, has gained acceptance in recent years [5, 8]. Although many surgeons still hesitate to perform such by-passes, these are often
the only alternative to limb amputation, with equivalent results to more proximal reconstructions .
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