What are the operative steps to expose the anterior tibial artery (ATA) and the peroneal (fibular) artery?

Operative Exposure of the Anterior Tibial Artery (ATA) and Peroneal Artery

The anterior tibial artery is best exposed through a medial transmembranous approach in its middle third, while the peroneal artery requires a medial approach for the proximal third and fibular resection for distal exposure.

Anterior Tibial Artery Exposure

Medial Transmembranous Approach (Middle Third)

This is the preferred technique for accessing the ATA in its middle third 1:

Patient Positioning:

• Elevate the limb
• Flex the leg
• Place thigh in external rotation

Incision:

• Follow the course of the great saphenous vein
• Begin 10 cm above the tibial malleolus
• Make a 10 cm longitudinal incision

Dissection Steps:

1. Gently disinsert the soleus and flexor digitorum longus muscles
2. Retract the tibialis posterior muscle
3. Split the interosseous membrane to expose the ATA

Key Anatomical Consideration: The ATA pierces the interosseous membrane approximately 50.9 mm (or 66.5% of the tibial plateau mediolateral width) distal to the tibial joint line 2. This measurement is critical for surgical planning and represents the safe distal limit for posterolateral approaches.

Proximal ATA Exposure (Medial Popliteal Extension)

For proximal ATA access 3:

• Extend the standard below-knee popliteal artery approach medially
• This "poplitealizes" the anterior tibial artery
• Provides excellent access for anastomosis
• Particularly suited for in situ saphenous vein bypass

Advantages: Shorter graft length, easier graft alignment, protects the peroneal nerve, avoids lateral counterincision.

Alternative: Lateral Approach

A lateral approach with fibular resection can access both the ATA and peroneal artery 4, though this is less commonly used for isolated ATA exposure.

Peroneal Artery Exposure

Proximal Third: Medial Approach

The peroneal artery can be exposed medially in its proximal third using the same approach as the posterior tibial artery 5:

• Extend the below-knee popliteal artery exposure medially
• Access through the deep posterior compartment

Distal Peroneal Artery: Fibular Resection Required

For distal peroneal artery exposure 5:

• Fibular resection is mandatory
• This provides adequate visualization of the distal vessel

Posterior Approach (Alternative)

A single posterior approach can access both the popliteal and anterior tibial arteries simultaneously 6:

Patient Positioning: Prone position

Steps:

1. Approach the lower popliteal artery posteriorly between the two gastrocnemius heads
2. Dissect the small saphenous vein 10 cm above the lateral malleolus
3. Retract the Achilles tendon and short fibular vessels medially
4. Divide the interosseous fascia over 10 cm
5. Medially rotate the limb by 30 degrees to expose the ATA
6. Consider 8 cm fibular resection if rotation alone provides inadequate exposure

Critical Pitfalls to Avoid

Vascular Nerve Branches: The ATA receives 2-3 vascular branches from the deep fibular nerve, with the first branch occurring approximately 33 mm from the fibular head 7. Preserve these during dissection to maintain arterial function.

Safe Dissection Limits: When using posterolateral approaches, limit dissection to 66.5% of the tibial plateau width to avoid ATA injury 2. The wide anatomical variation (range 45.7-86.7%) necessitates careful preoperative imaging.

Muscle Protection: Avoid excessive retraction or disruption of the tibialis posterior, flexor digitorum longus, and flexor hallucis longus, as nutrient arteries course through these muscles 8.