The difficulties involved in operating upon the small distal arteries of the leg have led to general pessimism and even to the idea that it is not really feasible to restore circulation by grafting distal to the level of the knee. To the factor of increased technical difficulty as vessel size becomes smaller is often added diffuse and distal atherosclerotic occlusions so that "run-off" circulation is poor. Any tiny clot which forms is apt to block the small lumen and lead to failure. The relatively gross technique possible in aortic procedures must be considerably refined to permit successful small arterial repair. Delicate maneuvers are mandatory, for the margin for error is not large.
Lack of appreciation of these factors has led to ill advised efforts by some to overextend certain procedures and to operate upon poorly chosen patients, with results which have raised doubts about the practicability of salvage of
DALE WA. Grafting Small ArteriesExperience with 19 Shunts Below the Knee. Arch Surg. 1963;86(1):22-33. doi:10.1001/archsurg.1963.01310070024004