Distal Venous Arterialization for Lower Limb Salvage: Angiographic Appearances and Interventional Procedures

Abstract

Approximately 14%-20% of patients with critical lower limb ischemia are unsuited for distal arterial reconstruction and face major distal amputation. Distal venous arterialization is a unique procedure in which the venous bed is used as an alternative conduit for perfusion of peripheral tissues. Eighteen patients with stage IV Fontaine critical lower limb ischemia underwent venous arterialization. Preoperative angiographic findings confirmed the absence of any below-knee continuous arterial vessels. The most distal satisfactory artery was used for proximal bypass anastomosis, and venous valves were destroyed with Parsonnet probes, cutting balloons, Fogarty catheters, and valvulotomes under radiologic guidance. All patients underwent intra- and postoperative angiography of the venous grafts and the distal venous bed. Primary and secondary graft patencies were 66% and 72%, respectively, at a mean follow-up of 25 months. The limb salvage rate was 83% overall and 75% at 2-year follow-up. Vascular imaging is essential in selecting and following up patients and in determining the appropriate intraoperative procedure.

The Anatomy and Physiology of the Venous Foot Pump

“…Instead, they defined the starting point of the lateral plantar vein as being between the first and second metatarsal bases deep to the heads of the adductor hallucis. This initial segment of the lateral plantar vein, as defined by Binns and Pho, corresponds to the deep plantar arch, described by several other authors (Tretbar, 1995;Engelke et al, 2001) and also in the present work.…”

“…The lateral plantar vein emerged between the oblique and transverse heads of the adductor hallucis. This section of the lateral plantar vein was consistent with the anatomical course of the deep plantar arch described by several other authors (Tretbar, 1995;White et al, 1996;Engelke et al, 2001). It was also found that the lateral plantar vein divided in two, approximately half way along its course.…”

“…In contrast to White et al, Tretbar proposed that blood in the deep plantar veins of the foot could be drained to the superficial system by means of inter-digital communicating veins to the dorsal arch or could remain in the deep system which is drained by the posterior tibial veins. It is important to note that Tretbar did not outline the methods used for his study, however, this general arrangement was consistent with the findings of several other studies (Binns and Pho, 1988;White et al, 1996;Engelke et al, 2001) and our own observations. A more conclusive anatomical study of the deep plantar veins of 14 cadaveric feet has been performed by Binns and Pho.…”

“…The inaccessibility of the deep veins of the foot has made the plantar venous plexus difficult to study in vivo. Several authors have provided angiographic evidence of the plantar plexus (Gardner and Fox, 1983;White et al, 1996;Engelke et al, 2001), which clearly demonstrates the presence of significant veins in the deep regions of the foot and goes some way to explaining the physiology of the foot pump (Fig. 1).…”

Arterialização do arco venoso do pé para tratamento da tromboangeíte obliterante

“…Tentativas de fazer chegar sangue arterial por via venosa retrógrada em territórios de grande isquemia datam do início do século passado com San Martin (1902 [6][7][8][9][10][11][12][13][14][15][16][17] . Os autores do presente trabalho, assim como Gasparis, mantêm a safena magna arterializada in situ 18,19 .…”