Endovascular Distal Plantar Vein Arterialization in Dialysis Patients With No-Option Critical Limb Ischemia and Posterior Tibial Artery Occlusion: A Technique for Limb Salvage in a Challenging Patient Subset

Gandini, Roberto; Merolla, Stefano; Scaggiante, Jacopo; Meloni, Marco; Giurato, Laura; Uccioli, L.; Konda, Daniel

doi:10.1177/1526602817750211

Cited by 39 publications

(34 citation statements)

References 13 publications

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“…Although further investigations enrolling larger patient populations are needed, these data should be considered very encouraging in dialyzed patients affected by CLI in relation to the high risk of major amputation historically recorded in this complex subset of patients. Even if the earliest theories about the arterialization of the peripheral venous bed were developed more than one century ago, 80 the mechanisms that may justify the benefits of venous arterialization for improving wound healing are still poorly understood, but reversed perfusion of arterioles through the arterial network of the foot and neovascularization stimulated by angiogenic factors seem to be the most likely explanations. 81…”

Section: Current Challenges and Future Perspectivesmentioning

confidence: 99%

Critical limb ischemia: current challenges and future prospects

Uccioli¹,

Meloni²,

Izzo³

et al. 2018

VHRM

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144

126

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Critical limb ischemia (CLI) is considered the most severe pattern of peripheral artery disease. It is defined by the presence of chronic ischemic rest pain, ulceration or gangrene attributable to the occlusion of peripheral arterial vessels. It is associated with a high risk of major amputation, cardiovascular events and death. In this review, we presented a complete overview about physiopathology, diagnosis and holistic management of CLI. Revascularization is the first-line treatment, but several challenging cases are not treatable by conventional techniques. Unconventional techniques for the treatment of complex below-the-knee arterial disease are described. Furthermore, the state-of-the-art on gene and cell therapy for the treatment of no-option patients is reported.

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Section: Current Challenges and Future Perspectivesmentioning

confidence: 99%

Critical limb ischemia: current challenges and future prospects

Uccioli¹,

Meloni²,

Izzo³

et al. 2018

VHRM

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144

126

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“…21,22 Peripheral revascularization is mandatory in patients with ischemic DFUs for allowing adequate restoration in the wound area 1,23 ; in the case of BTA-PAD, foot arteries should be revascularized (not only tibial arteries) to improve outcomes, using extreme revascularization techniques if required. 24-27…”

Section: Discussionmentioning

confidence: 99%

Limb Salvage in Diabetic Patients With Ischemic Heel Ulcers

Meloni

Izzo

Giurato

et al. 2019

The International Journal of Lower Extremity Wounds

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The purpose of this study is to investigate the outcomes of diabetic individuals with ischemic heel ulcers. The study group was composed of a consecutive sample of persons with diabetic ischemic foot ulcers managed by a preset multidisciplinary limb salvage protocol, including revascularization through endovascular technique. The outcome measures were healing, major amputation (above the ankle), and death at 1-year of follow-up. The outcomes between patients with heel ulcers (HUs) and without (NHUs) were compared. A total of 254 patients were recruited. There were 50/254 (19.7%) HUs and 204/254 (79.3%) NHUs. Overall, 190/254 (74.8%) patients healed. The rate of healing for HUs and NHUs was 30/50 (60%) and 160/204 (78.4%); P = .03, respectively. Major amputation occurred in 24/254 (9.4%) patients. The rates of major amputation for HUs and NHUs were 10/50 (20%) and 14/204 (6.9%; P = .002), respectively; 40/254 (15.7%) patients died, unhealed. The rates of mortality for HUs and NHUs were 10/50 (20%) and 30/204 (14.7%; P = .07), respectively. In HUs patients, absence of infection [95% CI = 3.1 (1.6-5.5); P = .002] and superficial ulcers [95% CI = 4.4 (2.2-9.3); P = .0001] were independent predictors of healing, whereas revascularization failure [95% CI = 8.1 (1.5.0-19.4); P = .0001], involvement of the plantar arch [95% CI = 6.3 (2.0-15.4); P = .0001], and dialysis [95% CI = 2.2 (1.3-4.5); P = .006] were independent predictors of major amputation. A multidisciplinary approach achieves good rate of limb salvage in people with diabetic ischemic heel ulcers.

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“…Although scarcely mentioned by the authors, other approaches for proximal pDVA (PIPER), 3 distal pDVA, 4 and the venous arterialization simplified technique (VAST) 5,6 have also consistently achieved equivalent results both for limb salvage and wound healing. 7 These alternative maneuvers should not be dismissed because the majority of the physicians are currently performing their pDVA procedures using these techniques owing to the limited availability and increased cost of the Limflow device.…”

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confidence: 99%

Commentary: Percutaneous Venous Arterialization: Should We Contain Our Enthusiasm?

Ysa

2020

J Endovasc Ther

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The outcomes of the ALPS study 1 published in the August 2020 issue of the JEVT are without doubt remarkable for a no-option chronic limb-threatening ischemia (CLTI) population. This retrospective multicenter study represents the largest population of patients (n=32) to date treated with percutaneous deep venous arterialization (pDVA) using the Limflow device (Limflow, Paris, France) with midterm results. The trial reports a 97% technical success rate, with limb salvage rates of 86.8%, 79.8%, and 79.8% at 6, 12, and 24 months, respectively, and corresponding complete wound healing rates of 36.6%, 68.2%, and 72.7%. These results are within the range for those previously reported by Mustapha et al 2 in the PROMISE I trial.Although scarcely mentioned by the authors, other approaches for proximal pDVA (PIPER), 3 distal pDVA, 4 and the venous arterialization simplified technique (VAST) 5,6 have also consistently achieved equivalent results both for limb salvage and wound healing. 7 These alternative maneuvers should not be dismissed because the majority of the physicians are currently performing their pDVA procedures using these techniques owing to the limited availability and increased cost of the Limflow device.Despite these encouraging results, the exact mechanism of action of pDVA remains unclear. It has been suggested that the use of the venous bed as a conduit for perfusion successfully increases flow through existing hibernating collaterals, improves tissue perfusion and nutrition in the capillary beds, and stimulates angiogenesis. 2 As a result, DVA improves microvascularization in target skeletal muscles and reduces ischemic markers, with a reduction in venous lactate. 8 Moreover, in the ALPS trial 1 (as in other studies), TcPO 2 , a reliable predictor of wound healing, rose to significant levels 6 to 8 weeks after DVA (45 days postprocedure).At this time there are also several practical aspects to pDVA that generate controversy and remain unsolved. Below are a few of these questions.

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Endovascular Distal Plantar Vein Arterialization in Dialysis Patients With No-Option Critical Limb Ischemia and Posterior Tibial Artery Occlusion: A Technique for Limb Salvage in a Challenging Patient Subset

Abstract: Although further investigations are required, distal plantar venous arterialization may represent a promising technique to improve recanalization rates and limb salvage in diabetic ESRD patients with extremely calcified PTA occlusions.

Cited by 39 publications

References 13 publications

Critical limb ischemia: current challenges and future prospects

Critical limb ischemia: current challenges and future prospects

Limb Salvage in Diabetic Patients With Ischemic Heel Ulcers

Commentary: Percutaneous Venous Arterialization: Should We Contain Our Enthusiasm?

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