To evaluate factors for the optimal outcome after tibial arterial bypa
ss for lower extremity ischemia, we analyzed our experience with 1,359
such bypasses during the last ten years. There were 869 males and 490
females, of whom 739 patients (54 percent) had diabetes. The average
age was 68 years. One thousand and twenty-four bypasses were performed
using the atraumatic valve incision in situ technique, 281 by passes
using free vein grafts and 54 bypasses with synthetic materials. These
bypasses were taken to the anterior tibial (312 patients), posterior
tibial (341 patients), peroneal (520 patients) and dorsalis pedis arte
ries (125 patients). Inflow arteries included external iliac (two pati
ents), common (435 patients), superficial (472 patients) and profunda
femoris arteries (259 patients). In certain instances, popliteal and t
ibial arteries were used for inflow (short bypasses). Limb salvage was
the significant indication (95 percent). The overall cumulative prima
ry patency rate at five years was 68 percent and secondary patency was
76 percent. In situ bypasses had the best secondary patency rate of 8
0 percent at five years followed by free vein grafts of 70 percent and
synthetic bypasses of 33 percent. The choice of inflow or outflow art
eries did not influence the patency rate in any category. The overall
limb salvage rate was 94 percent at five years. Short bypasses using f
ree vein grafts had a similar patency to long free vein graft but lowe
r patency than long in situ bypasses. These data demonstrate that bypa
sses to tibial arteries, using autogenous vein for ischemia of the low
er extremity and limb salvage, have long term durability. In situ bypa
ss with a complete saphenous vein is the best conduit for such reconst
ructions. We suggest that tibial arterial bypass should be strongly co
nsidered in all instances for limb salvage when autogenous vein is ava
ilable before resorting to primary amputation.