In situ devalvulated small saphenous vein for distal popliteal-peroneal and popliteal-posterior tibial bypass in patients with chronic limb-threatening ischemia: A multicenter case series.

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.