The number of cardiovascular patients with diabetes and associated diabetic foot disease has dramatically increased during the past decade. Diabetic foot ulcers (DFUs) are wounds below the malleoli in patients with diabetes and they are caused by a combination of factors, such as nerve damage, peripheral artery disease (PAD) and immune system dysfunction. As we know, 85% of diabetes-related amputations are preceded by a DFU. Nevertheless, with early detection and a high-quality care, a higher percentage of DFUs can be healed mostly with endovascular procedures but distal bypasses are associated with improved clinical and hemodynamic outcomes.

We illustrated the case of 78-year-old man with metabolic syndrome including type 2 diabetes insulin dependent, renal insufficiency and PAD. He presented symptoms that lasted 6 weeks and because of the lack of early detection, he developed necrosis of his foot fingers. Duplex-scan and computed tomography angiography (CTA) revealed severe below the knee arterial disease with occlusions of the three arteries and only patency of the distal peroneal and retro-malleolar posterior tibial arteries. The patient underwent previous posterior tibial artery endovascular revascularization attempt in a previous centre. After multidisciplinary team assessment, limb salvage procedure was decided and an extra-anatomic popliteal to distal peroneal artery bypass using reversed saphenous vein graft with a transtibial route was performed. Revascularization was associated with 4th et 5th metatarsal amputation. Postoperative course was uneventful and amputation healed in four months. The 12-months Duplex-scan and CTA showed bypass patency (picture).

This type of bypass requires an external approach of the peroneal artery after fibula bone resection but the infrequent transtibial route offers smaller incisions and a shorter way between popliteal and peroneal approaches, compared to anatomical route.

Transtibial route of distal peroneal bypass offers many surgical advantages without compromising the mid-term patency.