Percutaneous deep venous arterialization with balloon angioplasty salvaged a life‐threatening critical limb in a hemodialysis patient after repeated pedal angioplasty failed: A case report

Abstract

Chronic limb-threatening ischemia (CLTI) with severe below-the-ankle (BTA) lesions is often difficult to revascularize with endovascular treatment (EVT) and surgical treatment. We present a case of successful limb salvage using percutaneous deep venous arterialization (pDVA) in a patient with CLTI whose BTA lesion reconstruction failed. A 57-year-old man with diabetes mellitus and end-stage renal failure on maintenance hemodialysis was referred to our hospital because of gangrene in the second and third toes of his left foot. EVT was repeated for the anterior tibial artery, posterior tibial artery (PTA), dorsal foot artery, and plantar artery lesions; however, revascularization below the ankle was unsuccessful.As the infection had spread to the sole of the foot, below-the-knee amputation was indicated, but the patient refused. Therefore, we performed pDVA on the left PTA simultaneously with a Lisfranc amputation. An arteriovenous fistula was created at the ankle joint using a Venous Arterialization Simplified Technique and a guidewire was inserted into the plantar vein. Balloon dilatation from PTA to the plantar vein was performed to complete the pDVA. Although repeated EVT was required to maintain blood flow in the pDVA, skin grafting was performed 3 months after the pDVA, the wound completely healed, and he was discharged 6 months after the DVA. The pDVA can be an option for limb salvage in patients with no-option CLTI who are confronted by imminent amputation.

Percutaneous Deep Venous Arterialization for Limb Salvage in No Option Patients with Chronic Limb-Threatening Ischemia

“…Due to the lack of reproducibility and standardization of the procedure, DVA has been attempted in multiple settings using tools and techniques currently available (i.e., 'off-label'). In studies where alternate techniques of venous arterialization have been used, technical and clinical success varied from 77% to 100% and from 29% to 75%, respectively [32]. A multicenter retrospective study in Japan, the DEPARTURE JAPAN Study, reported the results of pDVA using the off-the-shelf technique.…”

“…Reinterventions can be endovascular or/and surgical and are reported for occlusion, asymptomatic stenosis, infection of the stent-graft, and bleeding from a superficial vein adjacent to the granulating wound. A variety of techniques and devices are used during reintervention, including thrombolysis, mechanical thrombectomy, DCB angioplasty, and stenting [32].…”

“…Procedural time ranges from 90 min to 4 h. After the procedure, patients should be maintained on lifelong antiplatelet therapy (oral clopidogrel or aspirin) in combination with warfarin or direct oral anticoagulants for 3 months. A follow-up protocol for monitoring blood flow into the foot is necessary using duplex ultrasound [32]. The LimFlow system earned a CE mark in 2016 and FDA approval in 2023, and is available in Europe and the United States.…”

Percutaneous Deep Venous Arterialization for Limb Salvage of No Option Patients with Chronic Limb-Threatening Ischemia

“…In studies where alternate techniques of venous arterialization have been used, technical and clinical success varied from 77% to 100% and from 29% to 75%, respectively. 38 A multicenter retrospective study in Japan, the DEPARTURE JAPAN Study, reports the results of pDVA using the off-the-shelf technique. The VAST was used in 83.3% of the cases.…”

“…A variety of techniques and devices are used during reintervention, including thrombolysis, mechanical thrombectomy, DCB angioplasty, and stenting. 38 Challenges during pDVA using the LimFlow System include navigation through a complex pedal venous system and management of venous spasm. Pre-procedure ultrasound or venography contributes to identifying the venous anatomy and optimizing case planning.…”