Advertisement

Surgical Deep Vein Arterialization: Adding to the Armamentarium of Complex Limb Salvage

Published:April 12, 2022DOI:https://doi.org/10.1016/j.avsg.2022.03.036

      Background

      Patients with severe peripheral arterial disease with limited or nonexistent arterial runoff, the so-called “desert foot”, challenge efforts at limb preservation. Deep vein arterialization (DVA) involves incorporating a venous target as an outflow to achieve revascularization in these complex patients. We report outcomes in an initial series of patients undergoing DVA as a component of surgical bypass.

      Methods

      Over a 2-year period, 10 patients underwent bypass incorporating DVA due to severely disadvantaged runoff using a heparin-bonded expanded polytetrafluoroethylene conduit. Indications for surgery included tissue loss (8) or ischemic rest pain (2) in patients who had failed endovascular (3) or surgical (7) revascularization. Inflow arteries for bypass ranged from external iliac to below knee popliteal. Outflow anastomoses incorporated a common ostium arteriovenous fistula between anterior tibial (5), posterior tibial (2), peroneal (1) or plantaris pedis (2) arteries, and corresponding tibial veins. Prior to anastomotic completion, tibial vein valves were lysed to allow venous arterialization by a way of retrograde flow. Postoperative medical regimen included dual antiplatelet (2), antiplatelet plus anticoagulation (7), or anticoagulation alone (1).

      Results

      Primary patency was maintained in 7 of 10 grafts (average: 4.1 months, range: 1–18 months). Limb salvage was achieved in 8 of 10 patients (average: 6 months, range: 1–18 months). Two below knee amputations were performed after graft occlusion due to extensive tissue loss and infection, whereas 1 patient maintained limb salvage despite graft occlusion after successful wound healing.

      Conclusions

      This initial experience describes surgical DVA using a prosthetic conduit in conjunction with an arteriovenous fistula at the distal anastomosis in patients with threatened limb loss and severely disadvantaged tibial runoff. Although evidence for long-term efficacy is uncertain, preliminary outcomes warrant further investigation as this technique may allow for surgical revascularization resulting in limb preservation for patients with no other alternative than amputation.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Dua A.
        • Lee C.J.
        Epidemiology of peripheral arterial disease and critical limb ischemia.
        Tech Vasc Interv Radiol. 2016; 19: 91-95
        • Nehler M.R.
        • Duval S.
        • Diao L.
        • et al.
        Epidemiology of peripheral arterial disease and critical limb ischemia in an insured national population.
        J Vasc Surg. 2014; 60: 686-695.e2
        • Norgren L.
        • Hiatt W.R.
        • Dormandy J.A.
        • et al.
        Inter-society Consensus for the management of peripheral arterial disease (TASC II).
        J Vasc Surg. 2007; 45: S5-S67
        • Saeedi P.
        • Petersohn I.
        • Salpea P.
        • et al.
        Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: results from the International diabetes Federation diabetes Atlas, 9th edition.
        Diabetes Res Clin Pract. 2019; 157: 107843
        • Ho V.T.
        • Gologorsky R.
        • Kibrik P.
        • et al.
        Open, percutaneous, and hybrid deep venous arterialization technique for no-option foot salvage.
        J Vasc Surg. 2020; 71: 2152-2160
        • Neville R.F.
        • Attinger C.
        • Sidawy A.N.
        Prosthetic bypass with a distal vein patch for limb salvage.
        Am J Surg. 1997; 174: 173-176
        • Neville R.F.
        • Dy B.
        • Singh N.
        • et al.
        Distal vein patch with an arteriovenous fistula: a viable option for the patient without autogenous conduit and severe distal occlusive disease.
        J Vasc Surg. 2009; 50: 83-88
        • Neville R.F.
        • Tempesta B.
        • Sidway A.N.
        Tibial bypass for limb salvage using polytetrafluoroethylene and a distal vein patch.
        J Vasc Surg. 2001; 33: 266-272
        • Neville R.F.
        • Lidsky M.
        • Capone A.
        • et al.
        An expanded series of distal bypass using the distal vein patch technique to improve prosthetic graft performance in critical limb ischemia.
        Eur J Vasc Endovasc Surg. 2012; 44: 177-182
        • Clair D.G.
        • Mustapha J.A.
        • Shishehbor M.H.
        • et al.
        Promise I: early feasibility study of the LimFlow system for percutaneous deep vein arterialization in no-option chronic limb-threatening ischemia: 12-month results.
        J Vasc Surg. 2021; 74: 1626-1635
        • Mustapha J.A.
        • Saab F.A.
        • Clair D.
        • et al.
        Interim results of the PROMISE I trial to investigate the LimFlow system of percutaneous deep vein arterialization for the treatment of critical limb ischemia.
        J Invasive Cardiol. 2019; 31: 57-63
      1. The PROMISE II trial, percutaneous deep vein arterialization for the treatment of Late-stage chronic limb-threatening ischemia - full Text View - ClinicalTrials.gov.
        • Alexandrescu V.
        • Ngongang C.
        • Vincent G.
        • et al.
        Deep calf veins arterialization for inferior limb preservation in diabetic patients with extended ischaemic wounds, unfit for direct arterial reconstruction: preliminary results according to an angiosome model of perfusion.
        Cardiovasc Revasc Med. 2011; 12: 10-19
        • Ferraresi R.
        • Casini A.
        • Losurdo F.
        • et al.
        Hybrid foot vein arterialization in No-option patients with critical limb ischemia: a preliminary report.
        J Endovasc Ther. 2019; 26: 7-17