Selection of Anastomosis Site in Peripheral Vascular Disease

Principles of Anastomosis Site Selection

The American College of Cardiology recommends using the most distal viable artery as the inflow source to preserve more proximal vessels for future revascularization procedures 1, 2
The proximal anastomosis should originate from an artery with continuous flow from above and stenosis ≤20% to ensure adequate hemodynamic inflow 1
Anastomose to the tibial or pedal artery that provides continuous and uncompromised outflow to the foot, even if this requires a longer bypass 1

For lower extremity bypass, anastomose to the most distal tibial or pedal artery capable of providing continuous outflow to the foot 1
Femoral-popliteal bypass: Anastomose to above-knee popliteal when adequate outflow exists 1
Femoral-tibial bypass: Use autogenous vein and select the tibial vessel with best continuous flow to the foot 1

The American College of Cardiology recommends duplex ultrasound as useful to select surgical bypass candidates and determine anastomosis sites (Class IIa recommendation) 3
MRA of extremities may be considered to select patients for surgical bypass and identify optimal anastomosis sites 3
Contrast angiography provides the most detailed anatomic information and should image iliac, femoral, and tibial bifurcations in profile without vessel overlap 3

Preoperative evaluation must document anatomic and functional status of arterial vasculature, including brachial artery flow 4
In diabetic patients, arterial calcification is more pronounced distally, so consider more proximal anastomosis sites in this population 5, 4
Hemodynamically significant stenosis is defined as >50% diameter reduction on angiography/ultrasound, supported by clinical symptoms and flow measurements 5, 6

Do not bypass distal sites prematurely by starting with proximal anastomoses, as this exhausts future revascularization options 2
Avoid subclavian vein access for dialysis catheters unless no other option exists, as this can jeopardize future permanent access 7
Do not place anastomoses in areas with >20% stenosis, as this compromises graft patency 1
Surgical expertise significantly impacts outcomes—early fistula failure rates are 3-fold higher with occasional surgeons versus experienced surgeons 5, 4

Axillofemoral bypass is reserved for patients with extensive aortoiliac disease who are not candidates for aortobifemoral bypass, with significantly inferior patency compared to aortobifemoral bypass 1