Abstract
Objective
Patients with chronic limb-threatening ischemia (CLTI) who have exhausted conventional endovascular strategies and lack an adequate great saphenous vein represent a challenging subgroup with limited limb salvage options. We evaluated the feasibility, durability, and clinical outcomes of distal popliteal-peroneal and popliteal-posterior tibial bypasses performed using an in situ devalvulated small saphenous vein (SSV) through a posterior prone approach.
Methods
A multicenter, retrospective-prospective observational case series was conducted across participating vascular centers. Consecutive patients undergoing distal popliteal-peroneal or popliteal-posterior tibial bypass using an in situ devalvulated SSV between January 2023 and December 2025 were included. Eligible patients presented with CLTI, absence of a suitable great saphenous vein, previous failed distal bypasses, and/or local infectious or anatomical conditions precluding a standard medial approach. Procedures were performed in the prone position through a posterior exposure. The primary end point was limb salvage at 12 months. Secondary end points included technical success, primary/primary-assisted/secondary patency, wound healing, amputation-free survival, and perioperative complications.
Results
A total of 11 patients were included. The mean age was 77 ± 11 years, and 73% were male. Diabetes mellitus was present in 100%, chronic kidney disease in 91%, and 36% were dialysis dependent. According to the Rutherford classification, 91% presented with tissue loss. Previous failed ipsilateral revascularization had occurred in 100% of limbs. Target vessels included the distal peroneal artery in four limbs and the retromalleolar/inframalleolar posterior tibial artery in seven limbs. Technical success was achieved in 100% of procedures. Thirty-day mortality was 0%, whereas early graft thrombosis occurred in 27.7%. At 12 months, primary, primary-assisted, and secondary patency rates were 63.6%, 72.7%, and 72.7%, respectively. Limb salvage was achieved in 72.7% of patients. Complete wound healing occurred in 100% after a median time of 6 weeks. Freedom from major adverse limb events was 72.7%.
Conclusions
Posterior popliteal-distal bypass using an in situ devalvulated SSV represents a valuable limb salvage strategy in highly selected patients with CLTI lacking conventional revascularization options. This technique allows the use of an entirely autologous conduit while avoiding hostile medial leg exposures. Acceptable patency and limb salvage outcomes can be achieved despite extreme anatomical complexity and previous treatment failures.
Keywords: Chronic limb-threatening ischemia, In situ vein bypass, Limb salvage, Popliteal-peroneal bypass, Popliteal-posterior tibial bypass, Small saphenous vein
Article Highlights.
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Type of Research: Multicenter retrospective observational case series evaluating posterior popliteal-distal bypass using an in situ devalvulated small saphenous vein (SSV) in 11 patients with chronic limb-threatening ischemia (CLTI)
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Key Findings: In highly selected CLTI patients lacking a suitable great saphenous vein and presenting hostile medial leg conditions, posterior popliteal-peroneal or popliteal-posterior tibial bypass using an in situ devalvulated SSV achieved 72.7% limb salvage at 12 months, with complete wound healing in 100% of surviving limbs after a median time of 6 weeks.
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Take Home Message: The posterior in situ SSV bypass represents a viable limb-salvage option for CLTI patients with exhausted conventional revascularization strategies, avoiding compromised medial surgical fields.
Chronic limb-threatening ischemia (CLTI) represents the most advanced clinical stage of peripheral artery disease and is associated with high risks of major amputation, cardiovascular events, mortality, impaired wound healing, and deterioration in quality of life.1, 2, 3 Contemporary guidelines emphasize that revascularization should be individualized according to patient risk, limb severity, anatomic pattern of disease, target artery quality, and conduit availability, with limb salvage and wound healing as the dominant goals in patients presenting with tissue loss.1, 2, 3
The optimal revascularization strategy in CLTI remains context dependent. The BEST-CLI (Best Endovascular versus Best Surgical Therapy in Patients with Critical Limb Ischemia) trial, demonstrated the advantage of surgical bypass over endovascular therapy in patients with an adequate single-segment great saphenous vein (GSV), whereas outcomes were less clearly favorable for surgery when suitable GSV was unavailable.4 Conversely, BASIL-2 (Bypass versus Angioplasty in Severe Ischaemia of the leg-2) trial suggested an advantage of a best endovascular treatment-first strategy in patients requiring infrapopliteal revascularization, underscoring that infrapopliteal CLTI cannot be reduced to a single algorithm despite the temptation to turn vascular surgery into a flowchart with delusions of grandeur.5
Autologous vein remains the preferred conduit for infrainguinal and infrageniculate bypass, particularly in patients with advanced tissue loss, long-segment occlusive disease, or limited endovascular durability.1,6,7 However, a substantial proportion of patients referred for complex limb salvage lack an adequate GSV because of previous bypass, prior harvesting, inadequate caliber, sclerosis, thrombosis, or varicose degeneration. In this setting, alternative autologous conduits are clinically important, because prosthetic conduits generally perform less favorably for below-knee targets and may be problematic in contaminated or infected fields.6, 7, 8
The small saphenous vein (SSV), historically referred to as the lesser saphenous vein, is an underused autologous conduit for distal lower extremity bypass. Contemporary series have shown that the SSV can provide acceptable patency and limb salvage when the GSV is unavailable, and comparative data suggest that it may represent a valid alternative to arm vein in selected patients.9, 10, 11 Its posterior location also creates an anatomic opportunity for popliteal-to-crural reconstruction through the same operative field.
The posterior prone approach to the popliteal and crural vessels has been described as a feasible alternative for popliteal-crural bypass, particularly when the peroneal artery is selected as the outflow target or when medial leg exposure is hostile because of infection, ulceration, scarring, or prior bypass surgery.12, 13, 14 Subsequent reports specifically combined posterior exposure with the use of the lesser or short saphenous vein, including in situ configurations, supporting the technical rationale for this approach in highly selected limb salvage patients.13, 14, 15, 16
Despite these historical and contemporary observations, posterior popliteal-distal bypass using an in situ devalvulated SSV remains poorly standardized and sparsely reported in the modern CLTI era, especially among patients who have undergone multiple previous endovascular or open revascularizations.
The purpose of this multicenter case series was to evaluate the clinical outcomes of popliteal-peroneal and popliteal-posterior tibial bypasses performed using an in situ devalvulated SSV through a posterior approach in the prone position in patients with CLTI and limited conventional revascularization options.
Methods
We conducted a retrospective, multicenter cohort study based on prospectively maintained institutional databases from two tertiary referral centers: Humanitas Research Hospital (Milan, Italy) and Campus Bio-Medico University Hospital (Rome, Italy). The case series included both retrospective and prospective data collection from participating vascular surgery centers with specific expertise in advanced limb salvage procedures. Consecutive patients undergoing posterior popliteal-distal bypass using an in situ devalvulated SSV, as shown in Fig 1, were included during the study period.
Fig 1.
Computed tomography angiography documenting a right popliteal-peroneal bypass using an in situ devalvulated small saphenous vein (yellow arrows).
The study population consisted of highly selected patients with CLTI who were considered unsuitable for conventional distal bypass strategies because of the absence of an adequate GSV, previous failed ipsilateral revascularizations, and/or the presence of hostile medial surgical fields related to infection, tissue loss, extensive scarring, or previous surgical exposure.
Eligible patients required distal surgical revascularization using popliteal inflow with a single available distal target vessel located at either the distal peroneal artery or the retromalleolar/inframalleolar posterior tibial artery. The availability of a suitable ipsilateral SSV was mandatory for inclusion.
Patients presenting with acute limb ischemia, inadequate SSV conduit, extensive posterior calf infection precluding posterior exposure, or limited life expectancy (<6 months) were excluded.
The study was conducted in accordance with the principles of the Declaration of Helsinki and approved by local institutional review boards when required. Written informed consent for surgery and data collection was obtained according to institutional policies.
All patients underwent comprehensive preoperative vascular assessment including duplex ultrasound vein mapping to evaluate conduit availability, SSV diameter, continuity, and anatomical suitability for in situ reconstruction. Cross-sectional imaging with computed tomography angiography and/or digital subtraction angiography was performed to assess inflow anatomy, distal runoff status, target vessel quality, and overall anatomical feasibility of posterior revascularization in selected patients. Although plantar arch patency is recognized as an important determinant of wound healing and limb salvage, it was not used as an inclusion criterion. The rationale behind this was that preoperative assessment relied primarily on computed tomography angiography, which has limited accuracy in evaluating functional plantar arch patency in patients with advanced CLTI and extensive below-the-ankle disease. Accordingly, patient selection was based on the quality of the available distal target vessel and the feasibility of establishing direct arterial inflow to the foot rather than on plantar arch patency.
Clinical severity was graded according to the Rutherford classification.
Attention was dedicated to the evaluation of local soft tissue conditions, previous surgical scars, active infection, and medial tissue loss to identify patients who could not benefit from conventional medial surgical exposure.
All procedures were performed with the patient in the prone position under general or locoregional anesthesia. Through a posterior approach to the popliteal fossa and calf, the SSV was identified, carefully dissected, and preserved in situ throughout its course by small incisions at the level of previously mapped collateral veins (Fig 2).
Fig 2.
Representative intraoperative image acquired during surgery by the authors and their collaborators of a posterior in situ exposure of the small saphenous vein, previously mapped via Doppler ultrasound imaging. The course of the small saphenous vein is shown by ink marks on the patient's leg.
The distal popliteal artery was exposed at either the supragenicular or infragenicular level according to individual anatomical characteristics and inflow suitability. Distal target vessel exposure was achieved through posterior or posteromedial dissection depending on the selected outflow artery and local anatomical considerations. Fig 3 shows the posterior exposure, more technically challenging, of the distal peroneal artery and of the SSV. The incision is performed at the distal third of the calf, lateral to the Achilles tendon. The fascia of the deep posterior compartment is cut. The Achilles tendon is retracted medially, and the flexor hallucis longus muscle is retracted laterally, exposing the peroneal artery. The artery runs along the medial border of the fibula, which serves as a reliable anatomical landmark and can be followed until it reaches its bifurcation into the perforating and communicating branches.
Fig 3.
Representative intraoperative image acquired during surgery by the authors and their collaborators showing posterior exposure in the prone position of the distal peroneal artery (yellow arrowheads) medially with respect to the fibula (black asterisk). Isolation of the small saphenous vein left in situ (blue arrowheads).
After systemic heparinization, proximal anastomosis was performed using standard vascular techniques (Fig 4). Valve lysis was then carried out with a LeMaitre) valvulotome under direct flow assessment to confirm adequate conduit function and restoration of antegrade arterial flow. Finally, distal anastomosis was completed in a standard fashion (Fig 5).
Fig 4.
Computed tomography angiography showing proximal anastomosis (orange circle) between the retrogeniculate popliteal artery (red arrowheads) and the in situ devalvulated small saphenous vein (SSV) (blue arrowheads).
Fig 5.
Computed tomography angiography showing distal anastomosis (orange circle) between the distal peroneal artery (red arrowheads) and the in situ devalvulated small saphenous vein (SSV) (blue arrowheads).
Completion intraoperative imaging with duplex ultrasound imaging and/or angiography was routinely performed according to institutional practice to confirm graft patency, adequate runoff, and absence of major technical defects requiring immediate revision.
The rationale for maintaining the conduit in situ included preservation of native venous geometry and tapering, reduced conduit manipulation, maintenance of vasa vasorum integrity, and avoidance of additional harvesting trauma. In addition, the posterior approach allowed avoidance of compromised medial tissue planes in patients with infection, ulceration, or previous surgical exposure.
Postoperative antithrombotic therapy was individualized according to patient comorbidities, distal runoff characteristics, and institutional protocols.
All patients were enrolled in a structured duplex ultrasound surveillance program. Surveillance examinations included assessment of graft patency, peak systolic velocities, velocity ratios across suspicious segments, inflow and outflow status, and identification of focal stenoses potentially requiring reintervention.
Routine duplex surveillance was performed before hospital discharge, at 1 month, 3 months, and 6 months postoperatively, and every 6 months thereafter. Additional imaging studies were obtained whenever clinical deterioration, recurrent ischemic symptoms, or duplex abnormalities suggested threatened graft patency.
All graft-related reinterventions, including endovascular or surgical revisions performed to maintain conduit patency, were prospectively recorded.
The primary study end point was limb salvage at 12 months, defined as freedom from major amputation above the knee in the treated limb. Given the extreme anatomical complexity and limited revascularization options of the study population, limb preservation was considered the most clinically relevant measure of procedural effectiveness.
Secondary end points were designed to evaluate both technical durability and overall clinical efficacy of the procedure. These included immediate technical success, primary patency, primary-assisted patency, secondary patency, wound healing outcomes, time to complete wound healing, amputation-free survival, perioperative morbidity, 30-day mortality, and graft-related reinterventions.
Technical success was defined as successful completion of the bypass with documented graft patency and adequate distal flow on completion angiography and/or intraoperative duplex ultrasound imaging.
Primary patency was defined as uninterrupted graft function without the need for any additional surgical or endovascular reintervention. Primary-assisted patency referred to maintained graft patency following prophylactic or corrective interventions performed before graft thrombosis occurred. Secondary patency was defined as restoration of graft function after documented occlusion through surgical or endovascular revision procedures.
Wound healing analysis included both complete epithelialization and freedom from major tissue loss progression during follow-up. Amputation-free survival was defined as survival without major amputation during the study period.
Perioperative complications included graft thrombosis, bleeding requiring reoperation, wound complications, systemic adverse events, and any other complication occurring within 30 days after surgery.
Major adverse limb events were defined as major amputation or major graft-related reintervention during follow-up. All reinterventions performed for threatened graft patency, recurrent ischemia, or graft failure were prospectively recorded and included both surgical and endovascular procedures.
Statistical analysis
Continuous variables were expressed as mean ± standard deviation or median with interquartile range according to distribution. Categorical variables were reported as frequencies and percentages.
Results
Between January 2023 and December 2025, a total of 492 patients underwent surgical lower-extremity revascularization for CLTI at the participating centers; of these, 11 patients (2.2%) underwent a lower limb revascularization via a posterior popliteal-distal bypass using an in situ devalvulated SSV. The mean patient age was 77 ± 11 years, and seven patients in the cohort were male. Comorbidities were highly prevalent, reflecting the complexity of the treated population: diabetes mellitus was present in all patients, chronic kidney disease in 10 patients, coronary artery disease in nine patients, and dialysis dependence in four patients.
Most patients presented with advanced CLTI and severe tissue loss. According to the Rutherford classification, one patient was categorized as Rutherford 4, five patients as Rutherford 5, and five as Rutherford 6. Previous ipsilateral endovascular revascularization had been performed in 100% of cases, whereas 80% of limbs had undergone prior bypass surgery, highlighting the hostile vascular and surgical background of this cohort. The posterior approach with in situ SSV reconstruction was selected based on the inclusion and exclusion criteria reported in the Methods section.
The distal target vessel was the distal peroneal artery in four limbs, whereas the retromalleolar or inframalleolar posterior tibial artery was used in seven limbs. Proximal inflow originated from the supragenicular popliteal artery in one case and from the infragenicular popliteal artery in 10 cases. Median operative time was 160 minutes. Technical success was achieved in 100% of procedures, as confirmed by completion angiography or intraoperative duplex ultrasound imaging.
Several adjunctive procedures were performed during the index operation. In particular the adjunctive procedures included one popliteal endarterectomy with patch angioplasty at the P1 (suprageniculate popliteal) segment, one distal angioplasty of the inframalleolar posterior tibial artery, five minor amputations, and five surgical debridements, according to intraoperative findings and limb status.
There were no deaths at 30 days. There were no perioperative complications, including graft thrombosis, bleeding requiring reoperation, or systemic complications. There were three wound complications necessitating surgical revision and vacuum-assisted clousre therapy. No early graft revision was required. Median postoperative hospital stay was 5 days.
Median follow-up duration was 12 months. At 6 months, estimated primary patency was 90.9%, primary-assisted patency was 100%, secondary patency was 100%, and limb salvage rate was 100%. One patient developed bypass stenosis requiring successful percutaneous transluminal angioplasty. No major amputations occurred during the first 6 months of follow-up. At 12 months, primary patency was 63.6%, primary-assisted patency was 72.7%, secondary patency was 72.7%, limb salvage was 72.7%, and amputation-free survival was 72.7%. Three bypass occlusions occurred during follow-up and were associated with major above-the-knee limb amputation.
Complete wound healing was achieved in 100% of surviving limbs after a median time of 6 weeks. Major amputation occurred in three patients and was associated with graft failure. During follow-up, late graft-related reinterventions included surgical thrombectomy, distal bypass revision, and balloon angioplasty for graft stenosis.
Discussion
This multicenter case series demonstrates that posterior popliteal-distal bypass using an in situ devalvulated SSV is technically feasible and can achieve clinically meaningful limb salvage in a highly selected cohort of patients with CLTI with limited remaining revascularization options. The study population reflects a particularly demanding contemporary phenotype: diabetes was universal, chronic kidney disease was frequent, most limbs presented with Rutherford 5 or 6 ischemia, all had undergone previous ipsilateral endovascular treatment, and most had a history of prior bypass surgery.
These findings should be interpreted within the current evidence landscape. Guidelines and randomized data support an individualized approach to CLTI revascularization, integrating limb threat, anatomic complexity, patient risk, and conduit availability rather than applying an indiscriminate endovascular-first or surgery-first strategy.1, 2, 3, 4, 5 The present cohort differs from the ideal surgical population with an available single-segment GSV evaluated in BEST-CLI; instead, it resembles the group in whom conventional algorithms begin to fray, because conduit availability, hostile surgical fields, and exhausted distal targets constrain standard options.4,6, 7, 8
The first relevant observation is the importance of preserving open surgical solutions for patients approaching a near no-option status. Repeated endovascular procedures may remain appropriate in many patients with infrapopliteal CLTI, as highlighted by BASIL-2, but restenosis, thrombosis, progressive runoff loss, and recurrent tissue loss can ultimately leave patients with few durable alternatives.5 In such cases, a short autologous bypass from popliteal inflow to a distal peroneal or posterior tibial target may offer a biologically favorable reconstruction while limiting the length of conduit required.
The posterior approach has specific anatomic and wound-related advantages. Historical series by Ouriel12 and by Goyal et al13 showed that popliteal-crural bypass through posterior exposure can be performed with acceptable early patency and limb salvage, particularly for peroneal targets as shown in Fig 3. In the present series, this approach also allowed avoidance of compromised medial tissue planes in patients with previous surgical scars, infection, tissue loss, or failed medial bypasses. This point is not cosmetic housekeeping; in CLTI, the incision is often another battlefield, because the soft tissues are damaged.
The SSV deserves greater attention as an autologous conduit. Nierlich et al9, 10, 11 reported favorable short- and long-term results with the SSV for distal autologous bypass, and subsequent comparative work suggested that the SSV and arm vein can both serve as valuable alternatives when the GSV is unavailable. These data are consistent with broader evidence showing that autologous conduits generally outperform prosthetic alternatives for infrageniculate bypass in CLTI, especially for distal targets and infected or contaminated fields.6, 7, 8
The in situ configuration may provide additional theoretical advantages compared with reversed or translocated grafting, including preservation of native tapering, reduced conduit manipulation, maintenance of the vasa vasorum, and avoidance of additional harvesting trauma. Although calf diameter was not evaluated as an outcome determinant in the present series, we acknowledge the anatomical hypothesis that a wider calf may increase the distance between the saphenopopliteal junction and the target crural artery, requiring more extensive vein mobilization; this warrants dedicated investigation in future studies. Prior reports of in situ lesser or short saphenous vein bypass support the feasibility of this technique, although the available literature remains limited and mostly based on small series or technical reports.15,16 Contemporary in situ saphenous vein data also emphasize the need for meticulous valve lysis, completion imaging, and structured duplex surveillance to identify correctable graft stenosis before thrombosis occurs.17
The 6-month patency and limb salvage observed in this series suggest that the technique can provide a useful window for wound healing in severely compromised limbs. At 12 months, graft failures were closely associated with major amputation, reinforcing that durability remains the central vulnerability of any distal bypass in this population. This finding is consistent with the broader CLTI literature, in which sustained patency, runoff quality, infection control, and wound healing are tightly linked clinical end points.1,17,18
The study also has practical implications. Preoperative duplex vein mapping is mandatory to confirm SSV caliber, continuity, and anatomic suitability. This concept is reinforced in our case series by the observation that patients who developed graft occlusion during follow-up had smaller mean proximal and distal SSV diameters (2.4 mm and 2.1 mm) compared with patients with patent grafts (3.1 mm and 2.8 mm) (Supplementary Table, online only). Cross-sectional or catheter-based imaging should define inflow quality, outflow target, pedal runoff, and the feasibility of a posterior route. Intraoperative completion imaging should be strongly encouraged, and postoperative surveillance should be systematic, because early detection and treatment of stenosis may preserve graft function and limb salvage.
In summary, posterior distal popliteal-peroneal and popliteal-posterior tibial bypass using an in situ devalvulated SSV expands the autologous limb salvage armamentarium for selected patients with CLTI without suitable GSV and with hostile medial leg conditions. The technique should not be viewed as a routine substitute for standard bypass or endovascular treatment, but rather as a specialized option for advanced vlimb salvage programs managing patients in whom conventional pathways have been exhausted.
The present study has several limitations. Its observational design introduces inherent risks of selection bias and confounding. The sample size is limited because of the rarity and complexity of the technique. The multicenter nature of the study may introduce variability in perioperative management, surveillance protocols, antithrombotic therapy, and thresholds for reintervention. No direct comparator group was available. Nevertheless, the rarity of the technique and the absence of contemporary multicenter data make this experience clinically valuable and hypothesis-generating.
Posterior distal popliteal-peroneal and popliteal-posterior tibial bypass using an in situ devalvulated SSV represents a feasible and effective limb salvage strategy in selected patients with CLTI lacking conventional revascularization options.
This technique allows fully autologous reconstruction while avoiding hostile medial surgical fields and may provide acceptable patency and limb salvage outcomes even in patients with advanced anatomical complexity and prior failed interventions.
Broader multicenter registries and comparative studies are warranted to further define the role of this strategy within modern CLTI treatment algorithms.
Author Contributions
Conception and design: DB, VC, FStilo
Analysis and interpretation: SB, NM, FSpinelli, EC
Data collection: NB, RS
Writing the article: NB, NM, FSpinelli, EC
Critical revision of the article: DB, SB, RS, VC, FStilo
Final approval of the article: DB, NB, SB, RS, NM, VC, FSpinelli, FStilo, EC
Statistical analysis: Not applicable
Obtained funding: Not applicable
Overall responsibility: EC
Funding
None.
Disclosures
None.
Footnotes
Additional material for this article may be found online at www.jvscit.org.
The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal Policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
Appendix
Additional material for this article may be found online at www.jvscit.org.
Appendix (online only)
References
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