Homemade Device to Facilitate Percutaneous Venous Arterialization in Patients With No-Option Critical Limb Ischemia

Abstract

Purpose: To describe a maneuver to facilitate percutaneous arteriovenous fistula creation during venous arterialization procedures in patients with no-option critical limb ischemia. Technique: Following a failed arterial recanalization attempt, a balloon catheter is passed up to the tip of the guidewire. Venous access is gained distally, a 4-F sheath is antegradely passed, and a 4-mm GooseNeck snare is advanced through it. A fluoroscopic view that overlaps the snare and the inflated balloon is obtained. If the vein remains anterior with respect to the artery, a needle is inserted across the vein, passing through the snare loop and puncturing the intra-arterial balloon. A wire is inserted and placed inside the punctured balloon. The balloon is retrieved and the wire externalized through the femoral access. A catheter is advanced antegradely over this wire from the artery into the vein. If the vein remains posterior to the artery, a needle is inserted, puncturing the balloon and thereafter the vein (crossing through the snare). A wire is inserted, captured by the snare, and externalized through the vein sheath. A catheter is finally advanced over this wire from the vein into the artery. Conclusion: This maneuver is a simple alternative to create an arteriovenous fistula during venous arterialization procedures in patients with no-option critical limb ischemia.

Midterm Outcomes of Percutaneous Deep Venous Arterialization With a Dedicated System for Patients With No-Option Chronic Limb-Threatening Ischemia: The ALPS Multicenter Study

“…Alternate techniques of venous arterialization have been reported. [23][24][25] In these studies, the arteriovenous fistula was created as distal in the tibial artery as possible. Technical success varied from 77% to 100%, with clinical success rates from 29% to 75% at various time points.…”

Percutaneous endovascular arteriovenous fistula creation for hemodialysis access using “off-the-shelf” conventional devices

“…Based on our previous experience in percutaneous venous arterialization procedures using "offthe-shelf" conventional devices in patients with no-option critical limb ischaemia 3 The fistula was first used 4 weeks following its creation with access flow at the brachial artery of 645 mL/min and so far no further interventions have been required.…”

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

“…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.…”