54 years old, male, Ex-smoker, Type II Diabetes, CKD stage 3, CVA stroke disease, Hypertension, previous left trans-metatarsal amputation.

Right lower limb CLTI, Rutherford 4-5, Fontaine IV, Wifi 7

Right lower limb angiogram, SFA severe disease, PTA, ATA occluded, moderately long occlusion of peroneal artery with the reformation in the mid third, the peroneal occlusion could not be crossed despite multiple attempts.(V18 guide-wire supported by Rubicon). Vein mapping, great saphenous vein proximal calf incomprehensible segment with echogenic thrombus, distal patent.

Surgical Technique:

With initial failed percutaneous angioplasty, distal peroneal artery as target arterial path (TAP) with a diameter of 2.68 mm and arterial duplex scan dorsal pedal and plantar artery monophasic.

An indirect revascularization was performed, Femoral to peroneal distal bypass via lateral with partial fibula resection , with non reversed great saphenous vein graft in-situ until knee and spliced reversed trans-located great saphenous vein to distal peroneal artery via lateral approach.

Lateral approach with partial fibula resection to improve exposure to the distal peroneal artery was described in 1974 by Dardik et al.

Dardik H, Dardick I, Veith FJ. Exposure of the tibial-peroneal arteries by a single lateral approach. Surgery 1974;75:377-83