Ultra-distal bypass remains a valuable option for tibial disease with tissue loss.

Background: The pattern of distal tibial calcific disease associated with chronic kidney disease (CKD) and diabetes is challenging to revascularize. Ultra-distal bypass, on to pedal or plantar vessels, is an option for patients who have failed an endovascular approach. The goal of such ultra-distal bypasses is often to achieve wound healing rather than long-term patency. We present a retrospective observational study from an Irish tertiary vascular center. Methods: A retrospective review of all ultra-distal bypasses since 2019 was performed. Cases were identified from theater logs. Electronic health records and formal charts were used to record demographics, comorbidities and outcomes. Statistical analysis was performed using SPSS. Results: Since 2019, 25 limbs in 23 patients underwent ultra-distal bypass for tissue loss, 16 to pedal vessels and 9 to plantars. All patients were male and the median age was 62.0 years (range, 43-85 years). Seventy-two percent (n = 18/25) of the cohort were diabetic, 36% had chronic kidney disease, 4 (16%) were dialysis dependent, and 5 (20%) had congestive heart failure. Median follow-up duration was 14 months (range, 0-51 months). At 12 months, freedom from graft failure was 68% (n = 17/25) and freedom from major amputation was 92% (n = 23/25). At the most recent clinic review, 85% (n = 17/20) of ulcers had healed. Conclusions: Ultra-distal bypasses are a valuable tool in a vascular surgeon's arsenal for tissue loss in patients with complex tibial disease. Although the durability of bypass was variable, the majority of patients included in this study healed their ulcers and only three limbs progressed to major amputation.