Blind peroneal artery outflow bypass for limb salvage in patients with severe CLTI: A case series

Limb loss carries a high risk of morbidity and mortality in patients with chronic limb-threatening ischemia (CLTI). Multiple medical and surgical strategies have been studied to address complications and lower amputation rates, especially in patients with poor outflow in the infrageniculate arteries. Our case series highlights the use of the peroneal bypass without angiographic runoff but acceptable intraoperative back-bleed as an option for patients with CLTI. A single-center retrospective review was performed on adult patients who underwent lower extremity bypass using the peroneal artery as the outflow for CLTI from 2012 to 2022. Two subgroups were classified as blind peroneal arteries and no-blind peroneal arteries, according to the Paty et al.'s 1998 classification. A total of twenty-five patients with lower extremity bypass for CLTI with the peroneal artery as the outflow target were included. From those, seventeen were classified as no-blind and eight were defined as blind peroneal, according to preoperative angiography runoff. Blind peroneal bypass primary patency rate was 45%, primary-assisted was 60%, and secondary was 60%, with a limb salvage rate of 75% at one and three years. Among the seventeen non-blind peroneal bypasses, primary patency was 45%, primary assisted was 60%, and secondary was 67.4%, with a limb salvage rate of 93.8% at one three years. There were no significantly different p-values observed between both groups. Blind peroneal bypasses serve as a last resort strategy to attempt limb salvage before amputation if adequate back-bleed is observed intraoperatively.