Purpose: To test the possible role of adjunctive AVF in maintaining patency of paramalleolar arterial reconstruction. 
Method: Eleven diabetic patients with critical leg ischemia due to extensive femoro-popliteo-tibial disease, with poor 
arterial runoff in the form of one patent paramalleolar tibial vessel connected to a diseased or partially occluded arch, were submitted to arterial reconstruction in the form of femoro-distal or popliteo-distal bypass with reconstruction of 
“common ostium" distal AVF. Clinical and duplex follow-up was done for these patients for at least 12 months. The outcome of this group of patients (group A) was compared to another group of 14 patients with critical limb ischemia and similar runoff, who underwent distal paramalleolar bypass without construction of AVF (group B). 
Result: One year patency rate for patients of group A was 64% while it was 50% for group B, while limb salvage rate 
was 73% for group A and 50% for group B. Above knee amputation was needed in 27% of patients of group A and 50% of patients group B. 
Conclusion: The reconstruction of distal AVF improve the patency of paramalleolar bypasses, and especially should be 
used with diseased or partially, occluded arch.