Crossing the Rubicon: A Closer Look at the Pedal Loop Technique.

The outcome of peripheral bypass surgery in patients at risk of limb loss is largely influenced by the anatomical integrity of the plantar arch. For this reason, in the last few decades, this area has been considered to be a sensitive territory, rarely approached surgically, and virtually untouchable by any endovascular activities. This hesitance was related to the possible damage to the thin dorsalis pedis, deep plantar, and lateral plantar arteries, together with the crucial metatarsal and digital branches arising from the arch. Twelve years ago, I argued that this area was anatomically very similar to the left anterior descending coronary artery and, thus, suitable for recanalization using standard endovascular coronary technique. Since its initial case, the pedal loop (PL) technique has become a very popular and glamorous procedure, likely performed in thousands of cases worldwide, additionally proving its efficacy in 2 large patient-registry retrospective analyses. Although the procedure is considered quite complex, from a technical point of view, it has almost no reliable alternatives in vascular and endovascular daily practice. However, by focusing attention on 12 well-established key points of the PL technique, it is likely that such may favor its diffusion among vascular surgeons and endovascular specialists.