What is an appropriate target vessel for distal runoff in patients with Peripheral Vascular Disease (PVD)?

Target Vessel Selection for Distal Runoff in PVD

The appropriate target for distal runoff in PVD is any tibial or pedal artery capable of providing continuous and uncompromised outflow to the foot, with the goal of establishing direct in-line blood flow to at least one vessel perfusing the foot. 1

Primary Target Vessel Criteria

The target vessel must meet specific anatomic requirements:

• Select the tibial or pedal artery that provides continuous, uncompromised outflow to the foot as the site of distal anastomosis 1
• The vessel should have continuous flow from above without stenosis greater than 20% 1
• Single-vessel runoff distal to the ankle is acceptable and may favor surgical revascularization over endovascular approaches in certain anatomic scenarios 1

Acceptable Target Vessels in Order of Preference

For surgical bypass, the hierarchy of target vessels includes:

• Above-knee popliteal artery when this provides adequate perfusion 1
• Below-knee popliteal artery when more distal flow is needed 1
• Tibial arteries (anterior tibial, posterior tibial, peroneal) when popliteal targets are inadequate 1
• Pedal arteries (dorsalis pedis, plantar arteries) in critical limb ischemia when more proximal vessels are diseased 1, 2

Alternative Targets When Standard Vessels Are Unavailable

When conventional targets are compromised, alternative approaches remain viable:

• Isolated popliteal arterial segment with collateral outflow to the foot is an acceptable revascularization target 1
• Composite sequential femoropopliteal-tibial bypass should be considered when no single adequate target exists with sufficient autogenous conduit 1
• In end-stage disease with no distal targets, percutaneous deep vein arterialization represents an emerging option before considering amputation 3

Critical Considerations for Target Selection

Runoff vessel adequacy directly correlates with limb salvage rates 1:

• The number of patent runoff vessels is the primary determinant of surgical success 1
• In acute ischemia from popliteal aneurysm thrombosis, catheter-directed thrombolysis should be used preoperatively to restore runoff and identify target vessels 1
• Failure to establish adequate runoff suggests atheroemboli or compartment syndrome requiring fasciotomy 1

Endovascular vs. Surgical Target Selection

For endovascular revascularization, the goal remains establishing in-line blood flow to at least one vessel perfusing the foot 1, 2:

• Staged approaches are reasonable, addressing inflow first and outflow subsequently if symptoms persist 1, 2
• Angiosome-guided therapy targeting additional infrapopliteal arteries beyond establishing in-line flow remains controversial and must be weighed against longer procedural times and contrast exposure 1

Factors favoring surgical over endovascular target selection include 1:

• Long segment lesions involving below-knee popliteal and/or infrapopliteal arteries when suitable single-segment autogenous vein is available
• Single-vessel runoff distal to ankle
• Small-diameter target artery or densely calcified lesions

Common Pitfalls to Avoid

• Never perform revascularization in asymptomatic PAD regardless of anatomic severity, as risks outweigh benefits 4
• Always attempt to restore runoff before declaring a limb unsalvageable—even heavily calcified pedal vessels may be targets with modern endovascular techniques 2
• Do not limit evaluation to non-invasive imaging alone in critical limb ischemia, as digital subtraction angiography with dedicated foot views may reveal targets not visible on CT or MR angiography due to calcification 2
• Avoid isolated below-knee revascularization for claudication alone—this should only be considered when performed with femoro-popliteal treatment if outflow is substantially impaired 4