New surgical and hybrid techniques for crural and pedal anastomoses

Although there is currently a trend using endovascular methods to treat long and/or complex distal lesions, there are some interesting new approaches, technical modifications and simplifications in open surgery. Some of these are new, and some are older, but their effectiveness is now starting to be recognized. 1) Anatomical concepts: the lower leg/foot consists of 6 angiosomes, which are supplied by the 3 main arteries. It has been shown that the revascularization of the correct angiosome could lead to a higher rate of success when compared to the connection of an indirect artery. Other anatomical concepts describe the use of a flow-thru flap, and the advances in the use of homografts in peripheral bypass surgery. 2) New materials for implantation: while biological graft materials (tissue engineering) are still under development, no fundamental changes in clinical use have taken place. If autologous vein is missing, alloplastic materials made from polyester or polytetrafluorethylene (PTFE) are the available alternatives. On the basis of studies published so far, heparin coating does appear to offer advantages. 3) New aids for operative treatment: in contrast to rather slow (clinical) advancement with regard to bypass materials, there have been some interesting developments with regard to ancillary products. There are clips for stapled anastomoses, small shunts or thermosensitive polymers to avoid clamping. Furthermore some techniques perform anastomoses without sewing, like intraluminal protein tubes or ring anastomoses. The Viabahn Padova Sutureless (ViPS) technique anastomoses a stent-graft to the artery by placing it openly into the vessel and then releasing a stent by a simple pulling mechanism. In summary, peripheral bypass surgery remains a very standardized operation. Although not spectacular, there are some interesting new approaches, technical modifications and simplifications.