Plantar Artery Research Articles

The medial plantar artery: anatomy and implications in local flaps of the foot

The medial plantar artery (MPA), as a terminal branch of the posterior tibial artery, provides perfusion to the musculature of the medial compartment of the plantar foot as well as cutaneous branches to the skin. The artery and its perforators serve as the foundation for several flaps based on various soft tissue components for the coverage of small defects of the foot. Most noteworthy is the fasciocutaneous flap, which utilizes the skin and the unique properties of the plantar foot. Understanding the anatomical relationship of the terminal branches of the MPA, the superficial and deep branches, is necessary in determining the type of tissue and the flap design to be utilized for reconstruction.

Analysis of the echogenicity and echotexture of the walls of the palmar and plantar digital arteries of horses and mules

Analysis of the echogenicity and echotexture of the walls of the palmar and plantar digital arteries of horses and mules

Soft tissue coverage of the ankle: An algorithm for appropriate flap selection and the experiences of a newly established Major Trauma Network

IntroductionReplication of the thin and pliable native skin around the ankle remains a challenge for plastic surgeons treating soft tissue defects in this region. Flap reconstruction constitutes the mainstay of management of such injuries. Subsequent management often entails revisional debulking surgery to permit normal footwear and an acceptable aesthetic outcome. In light of limited elective operating capacity throughout the covid-19 pandemic, we adopted an algorithm to inform reconstruction in such injuries and limit the need for revisional surgeries. This study presents this algorithm, which considers patient age, functional status, co-morbidities, body habitus and defect location. MethodsRetrospective analysis of a prospectively maintained database of all patients undergoing lower limb soft tissue reconstruction over 21 months was performed. All flap-based reconstructions of ankle defects were included; direct closures and skin grafts were excluded. All trauma patients were managed via a combined orthoplastic approach as per BOA-BAPRAS standards. All patients had Computed Tomography Angiography prior to their definitive reconstruction. Lower Extremity Functional Scale (LEFS) scores were analysed for patients with over 12 months of postoperative follow up, where available. Results71 flaps were performed in 69 patients. Open ankle fracture was the most common cause (86%); other indications included osteomyelitis and surgical wound dehiscence. Mean age was 50 (13–87 years) with a higher proportion of males to females (ratio 1.25:1). There were 26 pedicled flaps (18 Medial Plantar Artery and 8 Peroneus Brevis) and 45 free flaps (22 Anterolateral thigh, 11 Superficial Circumflex Iliac Artery Perforator, 11 Gracilis and 1 Medial Sural Artery Perforator). Mean follow-up is 13.6 months. There were three flap failures, and four patients subsequently underwent delayed below knee amputation despite successful soft tissue healing. For the patients with a minimum of 12 months follow up, LEFS scores with an average of 51% were achieved (range 15–88%). Four patients have been listed for revisional/debulking surgery. ConclusionAlthough soft tissue defects around the ankle can be difficult to manage, with careful planning and addressing each patient individually, supported by an algorithmic approach, good functional and aesthetic outcomes can be achieved with low rates of secondary revision surgery.

Medial Plantar Artery Perforator Kiss Flap for Salvage of Extensive Palmar Skin Defect.

Flaps based on the medial plantar artery (MPA) accomplish favorable surgical outcomes in palmar resurfacing because of their outstanding texture, pliability, and contour, but primary closure cannot be achieved at the donor site when the flap is designed to be relatively large. In this study, the kiss technique was used for the reconstruction of extensive palmar defects, which minimized donor-site morbidity. A modified flap surgical strategy was systemically developed based on the perforator distribution of the MPA through a cadaver study. Two or three narrow, small skin paddles based on the MPA were raised and resembled at the recipient site as a larger flap. Static two-point discrimination, hypersensitivity and range of motion, QuickDASH, gait, and patient satisfaction were evaluated 6 months to 12 months after the operation. From June of 2015 to July of 2021, 20 cases of reconstruction using the MPA perforator kiss flap were performed for the resurfacing of palmar skin defects. All flaps survived uneventfully, with coverage matching the texture and color of the recipients, except one flap that exhibited venous congestion and recovered after revision. Twelve flaps (60%) were double-paddled, and eight flaps (40%) were triple-paddled, with a resurfacing area of 27.19 cm 2 and 41.1 cm 2 , respectively. All donor sites achieved primary closure without major complications. Versatile kiss flap combinations were developed based on further understanding of the MPA system. Durable and pliable characteristics of the MPA perforator flap provide excellent reconstruction for extensive palmar defects while minimizing donor-site complications. Therapeutic, IV.

Estudo das artérias digitais palmares e plantares de equinos e muares por ultrassonografia modo-B e Doppler

ABSTRACT The present study aimed to evaluate and compare the palmar and plantar digital arteries of 10 horses and 10 mules through B-mode and spectral Doppler ultrasound. Likewise, compare the plantar arteries of the pelvic limbs with the palmar arteries of the thoracic limbs, in addition to verifying the differences of the digital arteries in the contralateral limbs (right and left) in horses and mules using B-mode and spectral Doppler ultrasonography. The evaluated parameters were the diameter and the intima-media thickness (IMT), resistivity index (RI), pulsatility index (PI), peak of systolic velocity (pSV), final diastolic velocity (fDV) and mean velocity (MV) of the lateral and medial palmar and plantar arteries digital in healthy horses and mules. The horses presented higher diameters values, IMT, pSV, fDV and MV in comparison to the mules. The variables RI and PI also presented differences between horses and mules. Also, both species showed higher values in the variables of B-mode and Doppler ultrasonography in the thoracic limbs. Differences were also detected in the comparison between the limb sides (right and left) in the two modalities. The B-Mode and spectral Doppler ultrasound techniques are viable tools to identify differences in the palmar and plantar digital arteries in healthy horses and mules, highlight the differences between the thoracic and pelvic limbs and their respective sides (right and left) as well.

Polyarteritis Nodosa: Gangrene in a Rheumatoid Arthritis Patient.

A 67-year-old Japanese woman with rheumatoid arthritis of 30 years duration presented with digital gangrene (Fig. 1) and diarrhea. The conventional angiography showed a left medial plantar artery aneurysm (an arrow, Fig. 2A), a left renal artery aneurysm (an arrow, Fig. 2B), and an ileocolic artery aneurysm (an arrow, Fig. 2C). Based on her symptoms and the results of the conventional angiography, she was diagnosed with polyarteritis nodosa. Gangrene of the lower limb in a patient with rheumatoid arthritis might suggest rheumatoid vasculitis or arterial occlusive disease, but both were unlikely due to the negative rheumatoid factor and the absence of atherosclerosis on computed tomography. Polyarteritis nodosa is typically a medium-sized vasculitis with visceral artery aneurysms, but microaneurysms may not be detectable on computed tomography or magnetic resonance imaging. In such cases, it may be advisable to perform conventional angiography to diagnose before organ damage occurs.FIGURE 1: Digital gangrene.FIGURE 2: The conventional angiography: (A) a left medial plantar artery aneurysm, (B) a left renal artery aneurysm, and (C) an ileocolic artery aneurysm.DIFFERENTIAL DIAGNOSIS Rheumatoid vasculitis, arterial occlusive disease, granulomatosis with polyangiitis, Behçet syndrome

Percutaneous deep venous arterialization with balloon angioplasty salvaged a life‐threatening critical limb in a hemodialysis patient after repeated pedal angioplasty failed: A case report

AbstractChronic limb‐threatening ischemia (CLTI) with severe below‐the‐ankle (BTA) lesions is often difficult to revascularize with endovascular treatment (EVT) and surgical treatment. We present a case of successful limb salvage using percutaneous deep venous arterialization (pDVA) in a patient with CLTI whose BTA lesion reconstruction failed. A 57‐year‐old man with diabetes mellitus and end‐stage renal failure on maintenance hemodialysis was referred to our hospital because of gangrene in the second and third toes of his left foot. EVT was repeated for the anterior tibial artery, posterior tibial artery (PTA), dorsal foot artery, and plantar artery lesions; however, revascularization below the ankle was unsuccessful. As the infection had spread to the sole of the foot, below‐the‐knee amputation was indicated, but the patient refused. Therefore, we performed pDVA on the left PTA simultaneously with a Lisfranc amputation. An arteriovenous fistula was created at the ankle joint using a Venous Arterialization Simplified Technique and a guidewire was inserted into the plantar vein. Balloon dilatation from PTA to the plantar vein was performed to complete the pDVA. Although repeated EVT was required to maintain blood flow in the pDVA, skin grafting was performed 3 months after the pDVA, the wound completely healed, and he was discharged 6 months after the DVA. The pDVA can be an option for limb salvage in patients with no‐option CLTI who are confronted by imminent amputation.

Revisiting Bipedicled Flaps for Lower Extremity Distal Third Defects.

Lower extremity reconstruction of the distal third of the leg is challenging. Free tissue transfer is the criterion standard. The COVID-19 pandemic encouraged seeking alternatives for resource consuming procedures. Bipedicled flaps are flaps with a dual-source subdermal perfusion. The purpose of this study was to assess outcomes of patients who had bipedicled flaps primary or auxiliary local flap for distal third leg/foot reconstruction. A retrospective review of patients undergoing lower extremity reconstruction (2020-2021) was performed. Inclusion criteria were patients older than 18 years with lower extremity wounds secondary to traumatic injury for which bipedicled flaps were used in the reconstruction. Exclusion criteria included lower extremity wounds secondary to peripheral vascular disease or diabetes. Fourteen patients were included in the study. All patients had distal third of the leg/foot wounds, and 12 patients (87.5%) had concurrent leg fractures. In 8 patients (57.1%), the bipedicled flap was used to decrease the wound size and facilitate another concurrent flap: hemisoleus (21.4%), anterior tibialis muscle turnover (14.3%), medial plantar artery (14.3%), and posterior tibial artery perforator (14.3%). Mean wound size for bipedicle flaps used alone was 42.0 ± 18.3 cm2, whereas wounds that required a bipedicled flap with an additional flap were 69.9 ± 80.8 cm2 (P = 0.187). Two patients had partial flap necrosis (14.3%) but healed their defect. One patient had nonunion (7.1%). Limb salvage rate was 100%. Bipedicled flaps can be used as an alternative to free flaps in distal third leg/foot defects in select patients. If distal extremity wounds cannot be covered with a bipedicled flap alone, the flap can be used an accessory flap to facilitate reconstruction with other local flaps.

Super-thin anterolateral thigh flap for reconstruction of the medial plantar artery perforator flap donor site.

The medial plantar artery perforator (MPAP) flap is widely used to reconstruct the weight-bearing area of the foot. Traditionally, its donor site is closed using a skin graft, which is associated with several complications, including walking disability. This study aimed to examine our experience with using a super-thin anterolateral thigh (ALT) flap to reconstruct the MPAP flap donor site. We examined 10 patients who underwent reconstruction of the MPAP flap donor site using a super-thin ALT flap between August 2019 and March 2021. The vascular pedicle was anastomosed to the proximal end of the medial plantar vessels or the end of the posterior tibial vessels. All reconstruction flaps survived and all patients were satisfied with the aesthetic appearance. No blisters, ulcerations, hyperpigmentation, or contractures occurred. All patients gained protective sensation in the super-thin ALT flap. The average visual analog scale score for the aesthetic appearance of the reconstructed foot was 8.5 ± 0.7 (range, 8-10). All patients were able to ambulate without aids and could wear regular shoes. The average revised Foot Function Index score was 26.4 ± 4.1 (range, 22-34). Reconstruction of the MPAP flap donor site using a super-thin ALT flap is reliable and provides satisfactory functional recovery, aesthetic appearance, and protective sensation while minimizing postoperative morbidity.

Combined Great Toe Dorsal Nail-Skin Flap and Medial Plantar Flap for Reconstruction of Degloved Finger Loss.

Historically, the degloved finger with the total loss of nails and skin has been resurfaced in two stages. Furthermore, proximal finger amputation requires an additional bone-tendon graft and an expanded great toe wraparound flap transfer for better outcomes. This article recommends a novel strategy to address these problems in a single stage using a dorsal nail-skin flap and medial plantar artery perforator flap. From March of 2015 to June of 2018, nine procedures were performed to resurface with skin loss to the metacarpophalangeal joint level, and three amputated fingers were reconstructed with an extra bone-joint-tendon graft simultaneously. The dorsal great toe donor was covered with a thin groin flap, and the medial plantar site was covered with a full-thickness skin graft. A standardized assessment of outcome in terms of sensory, functional, and aesthetic performance was completed. All flaps survived. The contour and length of the reconstructed digits were comparable with the contralateral finger. The mean static two-point discrimination was 11.0 mm (range, 9.0 to 14.0 mm). The average score of the Disabilities of the Arm, Shoulder, and Hand questionnaire and Michigan Hand Outcomes Questionnaire were 2.5 (range, 0 to 5) and 90.1 (range, 82 to 96), respectively. The mean Foot and Ankle Disability Index score was 95.6 (range, 93 to 99). At the last follow-up, the functional and aesthetic outcomes, and the restored sensation, were satisfactory for all fingers. This strategy may provide an alternative for selected patients seeking cosmetic resurfacing and functional reconstruction, preserving a weight-bearing plantar area with less morbidity. Therapeutic, IV.

Inframalleolar thrice distal puncture in a single endovascular treatment session for successful revascularization

BackgroundMost patients with chronic limb-threatening ischemia (CLTI) have infrapopliteal arterial disease, which are often challenging to treat. In endovascular treatment (EVT) for these complex lesions, establishing retrograde access is an essential option not only for guidewire crossing but also for device delivery. However, no EVT case has yet been reported requiring inframalleolar thrice distal puncture in a single EVT session so far.Case presentationA 60-year-old CLTI patient with grade 3 Wound, Ischemia and foot Infection (WIfI) classification underwent EVT for occluded dorsal artery and posterior tibial artery. First, we conducted successful balloon angioplasty of the posterior tibial artery by establishing a retrograde approach via the lateral plantar artery. To treat the occlusion of the dorsal artery, we punctured the first dorsal metatarsal artery, and retrogradely advanced a guidewire to the dorsal artery occlusion; however, the microcatheter could not follow the guidewire. Therefore, we punctured the occluded distal anterior tibial artery and introduced the retrograde guidewire into the puncture needle. After guidewire externalization, we pulled up the retrograde microcatheter into the occlusion of dorsal artery using the “balloon deployment using forcible manner” technique. Thereafter, we were able to advance the antegrade guidewire into the retrograde microcatheter. After guidewire externalization, an antegrade balloon catheter was delivered and inflated for the purpose of dorsal artery dilation and hemostasis at the “needle rendezvous” point. Consecutively, balloon dilation was performed for puncture site hemostasis of the first dorsal metatarsal artery and complete hemostasis was achieved. Finally, we confirmed good vascular patency and favorable blood flow. After revascularization, transmetatarsal amputation was performed and the wound healed favorably.ConclusionsWe can markedly increase the success rate of revascularization by effectively utilizing the retrograde approach in EVT for complex chronic total occlusions in infrapopliteal arterial diseases.

The role of great toe terminal branch artery split-thickness nail bed flaps in fingertip reconstruction surgery

The common treatments used to repair fingertip defects remain controversial. We have previously conducted research on split-thickness nail bed flaps, but this method still damages the proper plantar digital arteries and nerves. The great toe terminal branch arteries (TBAs) have not been described in detail. Twenty cadaveric feet were used to dissect the terminal branches of the plantar arteries. The locations and diameters of the terminal branches were analyzed. Five patients underwent operations with a TBA split-thickness nail bed flap. We recorded the recovery of both the donor and recipient sites and evaluated the results. The diameter of the TBAs was between 0.4 and 0.8mm. The TBA split-thickness nail bed flaps of five patients survived. No complications were found in any of the patients. The nail outcomes were excellent (A) in four patients and very good (B) in one patient. All patients were satisfied with the appearance of the recipient and donor sites. The mean static two-point discrimination was 6.0mm (range, 4-9). The mean Semmes-Weinstein monofilament test score was 3.03g (range, 1.65-3.84). Patients neither experienced severe pain in the reconstructed finger or at the donor site, nor did they experience severe cold intolerance. This microsurgical technique avoids the destruction of the proper plantar digital arteries and nerves. A TBA split-thickness nail bed flap from the great toe is clinically feasible and can achieve satisfactory results in fingertip repair. Therapeutic, V.

Enhanced Contraction of Arterial Smooth Muscle Cell in Skin Artery Is Sensitive to Hyperpolarization Mediated by BKCa Channel in Chronic Constriction Injury Model Rat.

Previous our study found that improvement of skin blood flow associated with neuropathic pain using vasodilators is useful for alleviation of neuropathic pain. In this study, we aimed to elucidate the mechanism underlying enhanced vasorelaxation induced by vasodilators, which increase cAMP and cyclic guanosine monophosphate (cGMP), in chronic constriction injury model rat. We assessed vasorelaxation effect of vasodilators by measurement of isometric contraction in isolated plantar artery from chronic constriction injury of sciatic nerve model rats. Nifedipine, a voltage-dependent Ca2+ channel inhibitor, NS1619, Ca2+-activated K+ (BKCa) channel opener, and diazoxide, an ATP-sensitive potassium channel opener, -induced vasorelaxation in ipsilateral plantar artery was enhanced compared to the these in contralateral plantar artery. Sodium nitroprusside (SNP), a nitric oxide (NO) donor, and substance P, a NK1 receptor agonist, caused vasorelaxation in both ipsilateral and contralateral artery. The vasorelaxation induced by SNP and substance P in ipsilateral artery is enhanced compared to the these in contralateral artery. Isoprenaline, a β adrenoceptor agonist, and salbutamol, a β2 adrenoceptor agonist, caused strong vasorelaxation in ipsilateral artery but not in contralateral artery. Iberiotoxin, a BKCa channel inhibitor, prominently suppressed the enhanced vasorelaxation induced by SNP, substance P, isoprenaline and salbutamol. In summary, the enhanced contraction of arterial smooth muscle cell in skin artery is sensitive to hyperpolarization in chronic constriction injury model rat. Furthermore, β adrenoceptor agonist would be a good drug to improve the decreased skin blood flow because it has selective vasorelaxation to ipsilateral plantar artery.

Vessel-by-Vessel Computed Tomography Calcium Scoring of the Foot in Peripheral Artery Disease: Association with Patient-Level Factors.

Objective: Peripheral artery disease (PAD) is associated with increased risk of nonhealing ulcers, amputation, and mortality due to occlusive atherosclerotic plaques. Computed tomography (CT) imaging detects vascular calcification in PAD; however, quantitative vessel-by-vessel analysis of calcium burden in the feet of PAD patients has not been assessed. This study sought to perform quantitative analysis of vessel-specific calcium burden and examine the patient-level determinants of foot calcium burden in PAD patients. Approach: PAD patients (n = 41) were prospectively enrolled and underwent CT imaging of the lower extremities. Manual segmentation of the medial plantar, lateral plantar, and dorsalis pedis arteries was performed. CT image Hounsfield units (HUs) were obtained for each artery to quantify vessel-by-vessel calcium mass using a cutoff value of ≥130 HU. Univariate analyses were performed to evaluate patient-level determinants of calcium burden for each foot artery. STROBE guidelines were used for reporting of data. Results: Univariate analyses revealed that body mass index, diabetes mellitus (DM), and chronic kidney disease (CKD) were significant determinants of foot calcium burden in PAD patients. Image analysis demonstrated that PAD patients with DM had significantly higher calcium mass for the medial plantar (p = 0.005), lateral plantar (p = 0.039), and dorsalis pedis (p = 0.001) arteries compared with PAD patients without DM. Innovation: This is the first study to use CT imaging to quantify vessel-specific calcium burden in the feet of patients with PAD and evaluate the patient-level determinants of foot calcium burden in the setting of PAD. Conclusion: CT imaging quantifies vessel-specific calcification in the feet of PAD patients, which is exacerbated with concomitant DM, CKD, and/or obesity.

Efficiency Of Medial Plantar Artery Flap in Patients With Plantar Defect: A Retrospective Study

Efficiency Of Medial Plantar Artery Flap in Patients With Plantar Defect: A Retrospective Study

Medial Plantar Artery Flap for Reconstruction of Weight-bearing Sole Defect- A Series of Ten Cases

Weight-bearing areas of feet are at risk of developing ulcers due to various reasons like a neuropathic foot in diabetes mellitus, acute trauma, post-tumour excision etc., Various reconstructive options have been described in literature from split-thickness skin graft to free flap. This case series reports 10 patients with sole defects. Out of 10 patients, seven patients had heel defect and three patients had the plantar aspect of the forefoot defect. For patients with heel defect, authors used a proximally based medial plantar flap as a reconstructive tool while for forefoot sole defect distally based (reverse) Medial Plantar Artery (MPA) flap was used. The most common cause of heel defect was postdebridement defect in diabetic foot in five cases, postmelanoma excision defect in three cases, postsquamous cell carcinoma excision defect in one case and postelectric burn defect in one case. Flap size ranged from 5x5 cm to 10×7 cm. All flaps offered stable, durable, and cosmetically acceptable skin cover. No patient had a recurrent ulcer during follow-up period. Partial flap necrosis in one case was managed conservatively. The MPA flap offers excellent cover which is a sturdy, durable, cosmetically acceptable cover for medium size defect over the sole i.e., the weight-bearing part of forefoot and heel.

A new method for second toe flap revascularization in plantar dominant artery pattern - dorsal metatarsal artery interpositional graf.

Toe transfer to hand is a viable option for patients, which can provide functionally useful digits. Harvesting of the second toe is still accepted as a demanding surgical procedure. The major questions before this transfer are the location and the dominance of the arterial anatomy of the second toe. The authors present the incidence of patients with a dominant plantar artery system and a description of a versatile technique that can be used for toe transfers in these patients. The study was designed retrospectively. Toe to hand transfers performed between 2010 and 2018 were reviewed. The patients with a dominant plantar arterial system were included in this study. The dorsalis pedis arterial graft technique described by the authors was used in all cases with a dominant plantar system. All of transfers were done by the senior author. All cases followed up at least one year post-operatively. The survival of the transferred finger was examined in the follow-ups. Eleven toe to hand transplantation cases in nine traumatic patients were included in this series. The reason for the operation was trauma in all patients. Second toe transfer was performed in all of the cases. Plantar dominant arterial system was seen in 3 of the 9 patients. Dorsal arterial system was dominant in the remaining six patients. Dorsalis pedis arterial graft technique was used in these four cases. All of the toes survived, and reexploration was needed in 2 cases because of venous insufficiency. Mean follow-up time was 16.4 months. This is the first study to recommend the use of dorsalis pedis as an arterial graft instead of vein grafts. This surgical method described will make these rarely performed transfers easier and affect the success rates positively.

Medial Plantar Artery Flap for Heel Reconstruction: A 22-year Follow-up

Medial Plantar Artery Flap for Heel Reconstruction: A 22-year Follow-up

RECONSTRUCTION OF PLANTAR SURFACE OF FOOT USING MEDIAL PLANTAR ARTERY FLAP- A CASE SERIES

Background: Reconstruction of weight bearing region of plantar foot defects present a challenge to surgeons because of lack of the options available and requirement of durable tissue. Among the limited options available medial plantar artery ap serve an ideal one. It can be raised in antegrade as well as retrograde fashion. In its anterograde form it is used for heel reconstruction and in retrograde form it is used for the reconstruction of the forefoot defect. The aim of this article is to assess Aim: the outcome of using medial plantar artery ap for reconstruction of heel and forefoot defect with a focus on ap survival, donor site morbidity and functional outcome. In the present study, we Material and method: present our experience with the use of medial plantar artery ap to cover plantar foot defect in the weight bearing region. Total of 12 patients, those underwent medial plantar artery ap re-construction, from January 2018 to January 2022 were included in this study. Out of the 12 patients Result: with the medial plantar artery aps, 10 were male and 2 were female. The indications for surgery were, traumatic tissue loss, unstable scar over previous grafted skin, neuropathic ulcer. All the aps survived, without major complications and provided adequate wound coverage with minimal donor site morbidity. Medial plantar artery ap for reconstruction of heel and forefoot i Conclusion: s associated with a very high ap survival rate with very few ap related complications including donor site complications.

Effectiveness of the Vascular Quality Initiative Chronic Limb-Threatening Ischemia Mortality Prediction Model in Patents with Distal Bypass

The purpose of this study is to evaluate the effectiveness of mortality prediction using the Vascular Quality Initiative (VQI) chronic limb-threatening ischemia (CLTI) model in patients with distal bypass. Patients who underwent distal bypass for CLTI from 2009 to 2020 at a single center were retrospectively reviewed. Distal bypass was defined as any bypass with a distal anastomosis to the posterior tibial, anterior tibial, dorsalis pedis, plantar, or peroneal artery. Baseline characteristics, operative details, hospital outcomes, and medium-term outcomes were compared among patients with a low-, medium-, and high-risk of mortality based on a VQI CLTI calculation. The primary endpoints were survival and limb salvage. A total of 287 distal bypasses were performed in 230 patients (153 males; median age, 74years; diabetes mellitus, 70%; end-stage renal disease [ESRD] with hemodialysis, 38%). These patients were stratified into 153 (66%) low-, 35 (15%) medium-, and 42 (18%) high-risk cases based on the VQI CLTI model. There were two hospital deaths (1%) within 30days. During a mean follow-up period of 33±29months, 105 patients died and 26 limbs (9%) required major amputation. The 2-year survival rate of 81% in the low-risk group was significantly higher than those of 41% in the medium-risk group and 46% in the high-risk group (both P<0.001). The 2-year survival rates did not differ significantly between the medium- and high-risk groups (P=0.81). The 2-year limb salvage rate of 93% in the low-risk group was significantly higher than those of 81% in the medium-risk (P=0.023) and those of 87% in the high-risk (P=0.039) groups. There were no significant differences in graft patency and wound healing among the three groups. These results suggest that distal bypass is optimal treatment for patients with a low VQI-predicted risk of mortality. However, the lower limb salvage and higher mortality rates at 2years suggest that the decision-making for VQI medium- and high-risk patients may be carefully considered.