Early results from an angiosome-directed open surgical technique for venous arterialization in patients with critical lower limb ischemia

Abstract

BackgroundPatients with critical lower limb ischemia without patent pedal arteries cannot be treated by the conventional arterial reconstruction. Venous arterialization has been suggested to improve limb salvage in this subgroup of patients but has not gained wide acceptance. We report our early experience after implementing deep and superficial venous arterialization of the lower limb.Materials and methodsTen patients with critical ischemia and without crural or pedal arteries available for conventional bypass surgery or angioplasty were treated with distal venous arterialization. Inflow was from the most distal unobstructed segment. Run-off was the dorsal pedal venous arch (n=5), the dorsal pedal venous arch and a concomitant vein of the posterior tibial artery (n=3), or the dorsal pedal venous arch and a concomitant vein of the common plantar artery (n=2) depending on the location of the ischemic lesion. Venous valves were destroyed using antegrade valvulotomes, guide wires, knob needles, or retrograde valvulotomes via an extra incision.ResultsSeven of the operated limbs were amputated after 23 (1–256) days (median [range]). The main reasons for amputation were lack of healing of either the original wound, of incisional wounds on the foot, or persisting pain at rest. In three cases, the bypass was open at the time of amputation. Two patients experienced complete wound healing after 231 and 342 days, respectively. By the end of follow-up, the last patient was ambulating with slow wound healing but without pain 309 days after surgery.ConclusionVenous arterialization may be used as a treatment of otherwise unsalveable limbs. The success rate is, however, limited. Technical optimization of the technique is warranted.

Commentary: Myths and Proofs of Angiosome Applications in CLI: Where Do We Stand?

“…[2][3][4][5][6][7][8][9][11][12][13][14] Despite being predominantly retrospective 3-8,14-18 studies rather than prospective 19 trials (although there are 3 recent meta-analyses 9,20,21 ), these articles offer somewhat encouraging results of ischemic wound healing for direct (angiosome-or wound-oriented) vs. indirect (wound-indifferent) arterial reconstruction whenever the former is feasible. [2][3][4][5][6][7][8][9][18][19][20][21] While most authors find the angiosome concept appropriate in distal bypass, 2,4,5,18 endovascular below-theknee (BTK) reperfusion, 3,[6][7][8]16 and even extreme deep vein arterialization, [22][23][24] others have reservations about acknowledging the benefits of surgical 25 or transcatheter 26 angiosome-guided distal leg revascularization.…”

Surgical revascularization and reconstruction procedures in diabetic foot ulceration

“…Open surgical arterialization of the superficial venous system of the foot can be achieved by performing a proximal anastomosis between the arterial system and the great saphenous vein and destroying the valves all the way down to the superficial venous arch . Alternatively, arterialization of the deep venous system is performed by making a bypass between the arterial system and a deep vein, for example, the posterior tibial vein, occluding the proximal part of the vein and destroying valves antegradely . In both cases, flow may be directed towards the ischemic part of the foot by closing collateral circulation.…”

“…Since incisions on the foot may have difficulties healing, some authors favour a hybrid approach performing distal anastomoses at the malleolar level, but destroying distal valves and closing side branches by endovascular means …”

“…In a subsequent, smaller study, we reported the results of open surgical, angiosome‐directed venous arterialization technique in 10 patients (8 with diabetes) with severe critical limb ischemia. During follow‐up seven patients had a major lower limb amputation and amputation could be avoided in three patients, although our later results tend to be better . Clearly larger studies with longer follow‐up are needed to determine if this technique could be used as a last resort approach in diabetic patients.…”

Isquemia e reperfusão por circulação retrógrada: estudo comparativo experimental

“…Diverting flow in a retrograde direction through the venous circulation is a feasible alternative that is supported by evidence from countless published studies. [1][2][3][4][5][6][7][8][9][10][11][12][13] The concept is based on the theory that in the absence of primary arterial blood pressure in arterioles, blood supplied by arterialization of the distal venous system is capable of supplying the peripheral tissues and providing adequate oxygenation. [3][4][5]13 Many different variables have been used to evaluate tissue hypoxia in animal models, such as assessment of arterial flow using Doppler ultrasound (US), 14,15 temperature measurements, 16 blood gas analysis, 17 lactate 18 and creatine phosphokinase (CP) assays, 19 and measurements of arterial blood pressure at extremities.…”