[Technical considerations and advances in distal bypass for chronic limb-threatening ischemia of the lower...

Chronic limb-threatening ischemia (CLTI) represents the end stage of lower extremity arterial disease and is associated with high rates of disability and mortality. With the rapid advancement of endovascular techniques, an "endovascular-first" strategy has become widely adopted. However, for patients with complex, long-segment, heavily calcified, diffuse, inflammatory lesions, or those with repeated endovascular failure, distal bypass surgery remains an indispensable option for limb salvage. The success of distal bypass depends not only on advanced surgical expertise but also on appropriate patient selection, accurate assessment of inflow and outflow tracts, optimal conduit choice, and meticulous perioperative management. Based on recent international guidelines and clinical evidence, this review focuses on key technical aspects of distal bypass, including inflow selection, target artery assessment, conduit selection, graft tunneling, distal anastomosis, intraoperative flow assessment, postoperative antithrombotic therapy and wound management. It also discusses the appropriate role of these techniques in the comprehensive treatment of CLTI based on recent evidence-based medical findings. In addition, emerging developments such as alternative conduits, perfusion assessment technologies, and gene/cell therapy are discussed, aiming to provide insights into optimizing revascularization strategies for patients with CLTI.