Hybrid Foot Vein Arterialization in No-Option Patients With Critical Limb Ischemia: A Preliminary Report

Abstract

To describe a preliminary experience in treating no-option critical limb ischemia (CLI) patients with a hybrid foot vein arterialization (HFVA) technique combining open plus endovascular approaches. Materials and Methods: Between May 2016 and January 2018, 35 consecutive patients (mean age 68±12 years; 28 men) with 36 no-option CLI limbs underwent HFVA in our center. All limbs had grade 3 WIfI (Wound, Ischemia, and foot Infection) ischemia, and the wound classification was grade 1 in 4 (11%) limbs, grade 2 in 4 (11%), and grade 3 in 28 (78%). Surgical bypass was done on the medial marginal vein or a posterior tibial vein, followed by endovascular removal of foot vein valves and embolization of foot vein collaterals. A "tension-free" surgical approach was used to treat foot lesions. Results: At a mean follow-up of 10.8±2 months, limb salvage was achieved in 25 (69%) limbs and wound healing in 16 (44%); 9 patients presented an unhealed wound. Eleven (31%) patients underwent a major amputation (2 below the knee and 9 thigh). One patient with an unhealed wound and open bypass died of myocardial infarction. Conclusion: HFVA is a promising technique able to achieve acceptable rates of limb salvage and wound healing in no-option patients generally considered candidates for an impending major amputation. Further studies are needed to standardize the technique and better identify patients who can benefit from this approach.

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

“…We hypothesize that a remodeling process takes place after pDVA. Ferraresi et al 8 reported the possibility of an angiographically detected remodeling process after DVA associated with clinical wound healing and high TcPO 2 measurements. We believe that longer time to wound healing in our study could be related to this remodeling process.…”

Surgical revascularization and reconstruction procedures in diabetic foot ulceration

“…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 …”

“…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. 16,18 Limb salvage after surgical venous arterialization is variable and the prognosis is difficult to predict for the individual patient. Lu amputation and amputation could be avoided in three patients, although our later results tend to be better.…”

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

“…This is a relevant aspect mainly in proximal pDVA because in distal pDVA a terminal anastomosis in the distal common plantar/lateral plantar veins reduces the probability of encountering valves that might obstruct blood flow. 11 Different strategies have been suggested for valve destruction: conventional or cutting balloons, wire-/catheter-based maneuvers, 12 or an antegrade valvulotome (ie, the Limflow system). It is hypothesized that the barotrauma of a balloon may predispose to future restenosis, 13 but these changes have been seen in only cadaver angioscopic studies.…”

“…Most authors perform venous collateral embolization on demand in case of insufficient clinical improvement, 1,5 while others recommend systematic focalization of blood flow to the wound by embolizing the proximal foot vein collaterals 14 to 28 days after the DVA procedure. 12…”