[Role of bypass surgery in crural arterial occlusive lesions].

The reconstruction of crural arterial lesions is crucial to salvage limbs in patients with diabetic atherosclerosis (DMASO). Crural arteries are often involved in DMASO, but paramalleolar or pedal arteries are rarely involved. Therefore, bypass surgery to the paramalleolar or pedal artery is the gold standard in this field. The paramalleolar or pedal bypass using a vein graft has the following advantages: 1) it supplies an efficient blood flow directly to ischemic tissue; 2) it is applicable in cases with poor run-off as well as severely calcified arteries which are difficult to treat using endovascular therapy (EVT); and 3) it yields an endothelialized surface with superior long-term results. Therefore, bypass procedures have become powerful tools to salvage limbs, especially with extensive tissue loss and severely calcified arteries in patients who are expected to survive more than several years. Comparing bypass and EVT in the crural area, bypass surgery is superior in terms of the clinical success rate as well as long-term clinical results. However, skills in and tools for EVT have advanced recently, and the type of arterial lesion, presence of severe calcification, severity of limb ischemia, quality of the vein, and patient longevity may be important keys in selecting bypass surgery or EVT as a treatment strategy.