When to Consider Surgical
Bypass
Jeffrey E. Indes M.D.
Assistant Professor of Surgery and Radiology
Section of Vascular Surgery
Yale University School of Medicine

No Disclosures

Tibial Artery Disease
Disea
Predictable Pattern
• In patients with diabetes, arteries
proximal to the knee joint are
often spared or moderately
diseased
• Majority of occlusions occur at
the tibial peroneal trunk and
distally.
• Often, the peroneal artery and
the dorsalis pedis artery are open
beyond these occlusions and
serve as potential distal targets
for a bypass.

Critical Limb Ischemia
TASC II, JVS, 2007

Why Not Surgery Every Time?
OPEN BYPASS
•Patency
•Clinical Durability
•Increased Morbidity and Mortality

Why Not Surgery Every Time?
OPEN BYPASS
•Patency
•Clinical Durability
•Increased Morbidity and Mortality
ENDO
•Minimize morbidity and mortality
•Goals
•Improve quality of life
•Limb salvage
•NOT PATENCY!!!!!

3x

3x

Exceptions to The Endo Rules
• Extensive tissue loss
• Infection
• In the setting of
extensive multi-level
occlusive disease
• Failed Endovascular
Treatment
• Hybrid Procedures

ENDO

Good Risk
OPEN

Poor Risk
ENDO

OPEN

Treatment Based on TASC
Classification for Tibials
Endo

Treatment Based on TASC
Classification for Tibials
Open

Vascular Surgeon’s View: Stop the
Drama on Lifestyle Limiting
Claudication
ENDO ! OPEN !

Bypass
• Inflow
• Target
• Conduit

Bypass with Vein
JAMIE D. SANTILLI, M.D., and STEVEN M. SANTILLI, M.D., PH.D.
University of Minnesota School of Medicine
Minneapolis, Minnesota

Bypass with
PTFE

Conclusions
• Bypass
– Disabiling Claudicants
who are “Healthy”
– Severe Multilevel
Disease
– Failed or Complicated
Endo

Special Thanks for Educational
Grant Support

Thank You