Combined Distal Venous Arterialization and Free Flap for Patients with Extensive Tissue Loss

Abstract

Aim:We evaluated the mid-term outcome of distal venous arterialization (DVA), and the role of a combined free flap as a bridgehead for blood supply. Methods:In the past 6 years, 9 patients with extensive tissue loss and lucking graftable distal arteries underwent DVA. These consisted of 4 primary DVAs, 3 combined DVA and free flap procedures, and 2 adjuvant DVAs for hemodynamically failed distal bypasses.After 9 primary DVAs, 3 redo DVAs were performed for early failure. Etiologies were 4Buerger's disease and 5 arteriosclerosis obliterans, including 3 dialysis patients.Results: Among the 9 DVA cases, there were 5 primary failures, consisting of 2 who underwent amputation, 2 had successful redo DVA, and the remaining one did not require redo-DVA. Primary patency, secondary patency, and limb salvage rates were 44.4%, 55.6%, and 77.8%. The postoperative period was 1-36 months (median 12 months). Angiography demonstrated DVA was effective in the early period, and development of collaterals or a capillary network from the free flap replaced the DVA function in the intermediate period.Conclusion: DVA can be effective as a procedure for limb salvage in patients without graftable distal arteries, and a combined free flap is effective and functions as a bridgehead for blood supply to the ischemic zone.

Skin Temperature in Lower Hind Limb Subjected to Distal Vein Arterialization in Rats

“…The peripheral tissues are fi nally lost because of the oxygen defi cit. Patients with AO often suffer severe pain, and may be treated by distal venous arterialization (DVA) in an attempt to save the distal parts of the lower limbs from amputation [ 1 ]. This procedure involves diverting an intact (non-affected) artery (posterior tibial artery or dorsalis pedis artery) and connecting it to the plantar vein below the ankle after the valves in the vein have been carefully disrupted and rendered incompetent.…”

A Review of Current Noninvasive Imaging Surveillance Practices for Deep Venous Arterialization Procedures

“…The Duplex ultrasound (DUS) study was the most frequently reported follow-up method followed by TCPo 2 and angiography. 6,[8][9][10][11][12][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31] Other methods infrequently used included ankle-brachial index (ABI), toebrachial index (TBI), toe pressure (TP), computed tomography (CT) angiography, and scintillography. 10,23 Duplex Ultrasound Some authors obtained DUS as early as 7 days postoperatively while one obtained the first DUS at week 6.…”

“…In contrast to noninvasive studies, four authors routinely performed digital subtraction angiography to evaluate venous arterializations. 18,19,22,23 Angiography can assess retrograde perfusion of the dorsal and deep plantar venous arches. 19 Additionally, angiography allows for interventions if the need is identified.…”

“…Stenotic valves can be addressed via valvotomy, thrombosis via thrombolytic medications, and collateral veins above the ankle via embolization. 22 No studies reported angiography parameters to guide decision making.…”

Thromboangiitis Obliterans

“…Distal venous arterialization may be offered as a last surgical resort for limb salvage in the absence of graftable distal arteries [185][186][187][188][189]. Distal venous arterialization can successfully salvage the critically ischaemic lower limb with few serious complications.…”