Midterm Outcomes From a Pilot Study of Percutaneous Deep Vein Arterialization for the Treatment of No-Option Critical Limb Ischemia

Comparison of Outcomes of Percutaneous Deep Venous Arterialization in Multiple Practice Settings

OBJECTIVE

To compare the efficacy of percutaneous deep venous arterialization in no-option chronic limb-threatening ischemia patients in the hospital versus office-based laboratory setting.

METHODS

A retrospective chart review was performed of all patients who underwent percutaneous deep venous arterialization using off-the-shelf devices from January 2018 to March 2023 in a hospital and an office-based laboratory. 73 eligible patients were identified, 41 hospital (59% male, median age (interquartile range) of 72 (18) years) and 32 office-based laboratory (59% males, 67 (16) years) patients. All eligible patients were deemed to have "no-option" critical limb ischemia, had at least 1 patent proximal tibial artery available for creation of the arteriovenous anastomosis, and were classified as having Rutherford category 4 or higher peripheral arterial disease. Patients were ineligible if classified as Rutherford category 3 or less, had active infection, did not have at least 1 appropriate venous target, and/or had rapidly progressing wounds requiring immediate major amputation. The primary outcome was major amputation-free survival. Secondary outcomes included technical success, limb salvage, survival, primary patency, re-intervention rate, adverse events, partial and complete wound healing. Outcomes were evaluated using Kaplan-Meier method, log-rank and two-stage procedure tests.

RESULTS

Technical success was achieved in 70 (96%) patients with 1 (2.4%) hospital and 2 (6.3%) office-based laboratory patients lost to follow-up. Major amputation-free survival estimates at 6 months, 1-year and 2-year were 51.4%, 40.4%, 30.2% in the hospital group and 69.4%, 54.0%, and 49.5% in the office-based laboratory group, respectively. Partial wound healing estimates at 6 months, 1-year and 2-year were 27.5%, 71.7%, 81.2% in the hospital group and 62.7% at all time points in the office-based laboratory group. Complete wound healing estimates at 6 months, 1-year and 2-year were 6.7%, 33.3%, 33.3% in the hospital group and 5.3%, 37.7%, and 41.6% in the office-based laboratory group, respectively. There was no significant difference in major amputation-free survival (p=.13), limb salvage (p=.07), survival (p=.69), primary patency (p=.53), partial (p=.08) or complete wound healing (p=.79) between groups. Re-intervention was performed in 8 (20.5%) hospital and 14 (45.2%) office-based laboratory patients.

CONCLUSION

Percutaneous deep venous arterialization is a feasible and safe procedure for no-option critical limb ischemia in the hospital and office-based laboratory setting without significant differences in outcomes at up to 2 years.

Technical Aspects of Percutaneous Deep Venous Arterialization Using Off-the-Shelf Devices

PURPOSE

Chronic limb-threatening ischemia (CLTI) represents the clinical end stage of lower extremity peripheral arterial disease (PAD). Although conventional open and endovascular revascularization options are available, some CLTI patients do not respond to these treatments, generally due to small vessel occlusive disease, with only limited or no clinical improvement achieved. This article aims to provide insights related to pertinent venous anatomy of the leg and below the ankle and a technical review of percutaneous deep venous arterialization (pDVA) creation using commonly-available devices.

TECHNIQUE

For patients with "no-option" CLTI, the risk of major amputation and mortality remains high. Although arterial revascularization remains the optimal treatment of CLTI, some patients with severely-diseased or gracile distal arteries have poor outcome. Deep venous arterialization (DVA), in a subset of patients with tibial anatomy amenable to DVA creation, represents the last-ditch attempt before these patients are deemed to have "no-hope" at limb salvage, and major amputation becomes necessary. Refinement in technique and advancement in device development have been shown to allow pDVA to be created with respectable outcomes for the "no-option" CLTI patient population.

CONCLUSION

The pDVA has garnered increasing interest among endovascular specialists to further understand the anatomical and technical key points of this procedure, and it may yet prove to be a useful addition in the armamentarium in our battle against CLTI.

CLINICAL IMPACT

Percutaneous deep venous arterialisation provides another option in the treatment of challenging "no-option" CLTI patients, and off-the-shelf devices will allow this procedure to be performed in centers where dedicated devices are not available.

Intravascular lithotripsy-assisted percutaneous deep vein arterialization for no-option chronic limb-threatening patients and heavily calcified tibial occlusive disease

PURPOSE

To report the first chronic limb-threatening ischemia (CLTI) patients who underwent an intravascular lithotripsy (IVL)-assisted percutaneous deep vein arterialization (pDVA).

CASE REPORT 1

An 81-year-old patient presented with CLTI and a heavily calcified lesion of the popliteal artery and tibioperoneal trunk (TPT), with a distal tibial and foot arch occlusion. The patient underwent IVL and drug-coated balloon angioplasty for the distal popliteal artery and of the TPT to improve the inflow prior to pDVA. The wound situation remained stable without secondary procedure until the patient`s deaths due to complications of urosepsis 3 months later.

CASE REPORT 2

A 64-year-old patient with rest pain of the left limb with a single-vessel tibial run-off (peroneal artery) and occluded pedal arch was treated with 3.5 mm IVL followed by a successful pDVA as mentioned above. IVL performed in the proximal posterior tibial artery to optimize the inflow to the circuit and change the compliance of the crossing point from the arterial to the vein system. The patient underwent repeat angioplasty of the plantar vein arch 5 months after the index procedure and thereafter remained asymptomatic during 2 years of follow-up.

CONCLUSION

The combined use of IVL and pDVA could improve the patency of the reconstruction with clinical benefits in no-option CTLI patients.

Transcatheter Arterialization of the Deep Veins for Limb Salvage

Critical limb-threatening ischemia is the most advanced stage of peripheral arterial disease, and patients with this problem represent a group at very high risk of limb loss. Until recently, patients with severe disease in the foot that was unreconstructable through the arterial system were relegated to treatment with wound care, pain management, and ultimately often faced major amputation. In recent investigations into the use of a percutaneous approach to venous arterialization, transcatheter arterialization of the deep veins has been evaluated as a mechanism to improve oxygen delivery to the foot in patients faced with the prospect of limb loss. Identifying patients who would benefit from this approach and a critical evaluation of the technique are provided along with expected outcomes. While the procedure remains in its infancy, early outcomes are promising, and continued advancement and improvement will further enhance options for these patients.

Efficacy and Durability of Percutaneous Deep Vein Arterialization: A Systematic Review

BACKGROUND

Endovascular deep vein arteriaization (DVA) is a novel technique aimed at salvaging peripheral arterial disease unamenable to conventional surgical intervention. This study aims to review contemporary literature on the efficacy, safety, and durability of DVA on patients with no-option critical limb ischemia (NO-CLI).

METHODS

The study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, using predefined search terms of "percutaneous deep vein arterialization" or "percutaneous deep venous arterialization" in PubMed, Web of Sciences, OvidSP, and Embase. Only studies with 5 or more patients were included, and studies involving open or hybrid DVA were excluded. The primary outcomes included technical success and primary amputation rates. Secondary outcomes included rates of wound healing, complication, reintervention, and all-cause mortality.

RESULTS

Ten studies encompassing a total of 233 patients were included. Patients were primarily those deemed to have NO-CLI. The median follow-up period was 12 months (range 1-63 months). The technical success rate was 97% (95% confidence interval [CI] 96.2%-97.9%) and the major amputation rate was 21.8% (95% 21.1%-22.4%). The wound healing rate was 69.5% (95% CI 67.9-71.0%), complication rate was 13.8% (95% CI 11.7%-15.9%), reintervention rate was 37.4% (95% CI 34.9%-39.9%), and all-cause mortality rate was 15.7% (95% CI 14.1%-17.2%).

CONCLUSIONS

Our study showed that endovascular DVA is safe for patients with NO-CLI. Nonetheless, studies were small with follow-up period of less than 1 year. There is currently lack of level 1 evidence to recommend routine use in patients with NO-CLI.

Below-the-Knee Endovascular Revascularization: A Position Statement

Patients with chronic limb-threatening ischemia, the terminal stage of peripheral artery disease, are frequently afflicted by below-the-knee disease. Although all patients should receive guideline-directed medical therapy, restoration of inline flow is oftentimes necessary to avoid limb loss. Proper patient selection and proficiency in endovascular techniques for below-the-knee revascularization are intended to prevent major amputation and promote wound healing. This review, a consensus among an international panel of experienced operators, provides guidance on these challenges from an endovascular perspective and offers techniques to navigate this complex disease process.

Percutaneous Deep Venous Arterialization in Patients with No-Option Critical Limb Ischemia Performed in an Office-Based Laboratory Setting

PURPOSE

To evaluate the feasibility and safety of percutaneous deep venous arterialization (pDVA) performed in an office-based laboratory (OBL) for patients with no-option critical limb ischemia (CLI).

MATERIALS AND METHODS

A retrospective chart review was performed of all patients who underwent pDVA using commercially available devices from January 2018 to November 2021 in a single OBL. In total, 22 patients (10 males and 12 females; Rutherford 4, 5, and 6: n = 1, 8, and 13, respectively) were identified with a median follow-up of 140 days. Amputation-free survival, wound healing, pDVA patency, and overall survival were evaluated at 30 days, 6 months, and throughout the remaining follow-up period.

RESULTS

All patients had undergone failed previous attempts at endovascular arterial reconstruction. At 6 months after procedure, 6.4% of arteriovenous conduits remained patent; 83.3% (10/12) of patients experienced complete or partial wound healing. In addition, 78.6% of patients avoided an above-ankle amputation, and overall survival was 83.6%. Nine patients underwent endovascular reinterventions at 6 months. One mild adverse event and 4 moderate adverse events occurred after procedure, and 1 cardiac death occurred 5 days after procedure.

CONCLUSIONS

pDVA is safe and feasible in the OBL for patients with no-option CLI. Many patients avoided an above-ankle amputation during the study period despite low overall pDVA patency.

Short-Term Outcomes and Efficacy of Percutaneous Deep Vein Arterialization for No-Option Critical Limb Ischemia: A Systematic Review and Meta-Analysis

BACKGROUND

Percutaneous deep vein arterialization (pDVA) is considered a treatment modality in patients with no-option critical limb ischemia. However, there is still a paucity of evidence regarding its safety and efficacy.

DATA SOURCES

MEDLINE (via PubMed), Embase and Web of Science databases as well as the CENTRAL registry up to the end of June 2023.

METHODS

This review adhered to the PRISMA guidelines (PROSPERO registration no. CRD42023445171). The risk of bias was assessed using the methodological index for non-randomized studies (MINORS). Primary endpoints included technical success, overall survival and limb salvage during the follow-up. Amputation-free survival at 30 days, 6 months and 1 year as well as complete wound healing, major adverse limb events and reintervention were investigated as secondary outcomes.

RESULTS

Five observational studies, comprising 208 patients (142 Rutherford class 5/77 Rutherford class 6), were included. MINORS revealed a low risk of bias. The meta-analysis reached a pooled technical success rate of 96.2% (95% CI: 91.5-98.4), an overall survival of 82.8% (95% CI: 70.5-95.2) and a limb salvage rate of 77.2% (95% CI: 65.2-89.1) during the follow-up. The amputation-free survival at 30 days, 6 months and 1 year was 87.8%, 68.7% and 65.6%, respectively. Furthermore, pDVA resulted in a complete wound healing rate of 53.4% (95% CI: 30.3-76.5). The pooled reintervention rate was as high as 46.7% (37.1-56.3%).

CONCLUSIONS

PDVA seems a feasible bail-out strategy for patients with no option for routine treatment of CLTI. However, due to the small number of studies, the strength of the evidence is low.

Endovascular and Surgical Venous Arterialization for No-Option Patients With Chronic Limb-Threatening Ischemia: A Systematic Review and Meta-Analysis

BACKGROUND

Chronic limb-threatening ischemia (CLTI) is known for its high rates of major amputation and mortality. Conventional revascularization techniques often fail in CLTI patients due to the heavily diseased arteries. Foot vein arterialization (FVA) has been proposed as an alternative technique to provide arterial blood to the foot by using the disease-free venous bed.

OBJECTIVES

This systematic review and meta-analysis aimed to determine outcomes of surgical FVA (sFVA) and percutaneous FVA (pFVA) at 6 and 12 months post-procedure.

DATA SOURCES

PubMed, Scopus, Web of Science, and the Cochrane Library databases were searched to identify papers reporting clinical outcomes of sFVA and pFVA published between January 1966 and March 2023.

METHODS

Databases were searched for eligible studies. A meta-analysis was performed to evaluate the limb salvage rate, overall survival rate, and wound healing rate at 6 and 12 months.

RESULTS

A total of 27 studies were included, with 753 patients and 793 limbs. Of the included studies, 16 analyzed the sFVA technique and 11 the pFVA technique. Of the included patients, 86.3% were Rutherford 5/6 in the sFVA group versus 98.4% in the pFVA group. The pooled limb salvage rate at 6 and 12 months was 78.1% and 74.1% in the sFVA group and 81.7% and 78.6% in the pFVA group, respectively. Wound healing rates were not reported in the sFVA group. In the pFVA group, the pooled wound healing rates were 48.1% and 64.5% at 6 and 12 months, respectively.

CONCLUSION

This study showed promising results after FVA among a large population of CLTI patients. In high-risk patients, pFVA is a feasible option with favorable limb salvage and wound healing rates.

Endovascular Interventions for Peripheral Artery Disease: A Contemporary Review

PURPOSE OF REVIEW

Peripheral artery disease (PAD) is an increasingly prevalent but frequently underdiagnosed condition that can be associated with high rates of morbidity and mortality. While an initial noninvasive approach is the cornerstone of management, revascularization is often pursued for patients with treatment-refractory claudication or chronic limb-threatening ischemia (CLTI). In this review, we discuss the current state of endovascular interventions for PAD and explore the many new emerging technologies.

RECENT FINDINGS

The last decade has resulted in numerous advances in PAD interventions including the ongoing evolution of drug-coated devices, novel approaches to complex lesions, and contemporary evidence from large clinical trials for CLTI. Advances in endovascular management have allowed for increasingly complex lesions to be tackled percutaneously. Future directions for the field include the continued evolution in device technology, continued development of state-of-the-art techniques to revascularization of complex lesions, and increased collaboration between a largely multidisciplinary field.

Off-the-shelf percutaneous deep vein arterialization for no-option chronic limb-threatening ischemia related to Buerger disease

Percutaneous deep venous arterialization (pDVA) is an important technique in the pursuit of limb salvage for a certain high-risk subset of patients with chronic limb-threatening ischemia (CLTI) considered to have "no option" owing to the lack of tibial or pedal targets for revascularization. pDVA seeks to establish an arteriovenous connection at the level of the tibial vessels, in addition to tibial and/or pedal venoplasty, to provide a pathway for arterial perfusion via the tibial and/or plantar venous system. A commercial system for pDVA exists; however, it is not yet approved by the U.S. Food and Drug Administration. In the present report, we detail a method of pDVA that uses commercially available devices for a patient with no-option CLTI related to Buerger disease.

Utility of BeBack crossing catheter in fistula creation during percutaneous deep vein arterialization

For patients with "no-option" chronic limb-threatening ischemia, a final attempt can be made for limb salvage in the form of percutaneous deep vein arterialization (pDVA). In the present study, we describe five cases of pDVA using a BeBack crossing catheter (Bentley InnoMed GmbH; previously, the GoBack crossing catheter; Upstream Peripheral Technologies). From November 2021 to July 2022, five patients underwent pDVA using the BeBack crossing catheter. The demographic data, procedural details, and patient outcomes were recorded. Successful vascular crossing was achieved in all five cases using the BeBack device. No surgical complications were encountered. The limb salvage rate was 60%, and the wound closure rate was 40%. No mortalities occurred during the follow-up period. The findings from the present study demonstrate that the use of the BeBack crossing catheter for pDVA is safe and feasible.

Hybrid superficial venous arterialization and endovascular deep venous arterialization

We report on two venous arterialization (VA) techniques for treatment of CLTI in patients traditionally considered as having no treatment options for standard arterial endovascular or surgical bypass procedures. Screening and the preprocedural workup findings are outlined as deciding factors in determining a patient's fitness for the two techniques, with a focus on careful preprocedure arterial duplex ultrasound and assessment for vein suitability. Cardiac and infection screening are also factors in determining patient suitability for VA. In addition, radiographic assessment for the presence of medial artery calcification, which is used as a marker of technical difficulty and is a predictor of poor outcomes, is required. Ultimately, anatomic factors are used to determine the decision between hybrid superficial VA and or endovascular deep VA. Those with an occluded anterior tibial artery and suitable great saphenous vein are prioritized to hybrid superficial VA, and those with an occluded posterior tibial artery to endovascular deep VA. Both procedures are described in detail in this report of vascular and surgical techniques.

Evaluation of the lower extremity blood supply in no-option critical limb ischemia patients with stem cell transplantation by time maximum intensity projection CT perfusion: A single-centre prospective study

OBJECTIVES

Cell therapy has had satisfactory safety and efficacy outcomes for no-option critical limb ischaemia (NO-CLI) patients. In the current study, we aimed to compare the image quality of ischaemic lower limb blood vessels shown on volumetric CT-based time maximum intensity projection CT perfusion (t-MIP CTP) versus single-phase CTA (sCTA). We also tried to quantify the blood flow of the ischaemic lower extremity based on the t-MIP technique, not only to precisely show the dynamic change in blood flow from before to after cell therapy but also to detect any relationship between this change and patient prognosis.

METHODS

A total of 31 patients with thromboangiitis obliterans (TAO)-induced NO-CLI who had been referred from the department of vascular surgery to undergo autologous stem cell transplantation into a single limb from January 2020 to March 2021 were prospectively enrolled in this study. Preoperative sCTA or t-MIP CTP and postoperative 1-month t-MIP CTP were performed in all patients. Clinical outcomes, including the 1-month ankle-brachial index (ABI) and 3-month CLI status, were also analysed. Image quality, including objective scores (attenuation, signal-to-noise ratio [SNR] and contrast-to-noise ratio [CNR]), subjective scores and collateral scores, was compared between preoperative sCTA and t-MIP CTP. Vascular volume was calculated as the total volume (mL) of lower limb arteries within the scanning range. All images and calculations were performed by 2 separate radiologists. Receiver operating characteristic curves were drawn to reveal the sensitivity and specificity of vascular volume and ABI in predicting prognosis.

RESULTS

Both sCTA and t-MIP CTP images exhibited good quality for diagnosis. t-MIP CTP images showed significantly higher attenuation, SNR and CNR in all arterial segments (popliteal artery, anterior tibial artery, posterior tibial artery and peroneal artery). In subjective and collateral score evaluations, t-MIP CTP images were also significantly better than sCTA images (both p < .05). At 1 month after transplantation, both vascular volume and ABI showed significant improvement (both p < .01). At 3 months after transplantation, 38.71% of patients (12/31) achieved CLI relief (Rutherford class < 4). Through the receiver operating characteristic (ROC) curve, the 1-month vascular volume increase ratio showed better ability to predict the 3-month prognosis (radiologist 1: AUC, 0.757; sensitivity, 0.750; specificity, 0.840; radiologist 2: AUC, 0.803; sensitivity, 0.500; specificity, 1.000) than the 1-month ABI increase ratio (AUC, 0.607; sensitivity, 0.230; specificity, 0.820) or 1-month ABI (AUC, 0.410; sensitivity, 0.080; specificity, 0.580).

CONCLUSION

t-MIP CTP showed significantly higher-quality images of ischaemic limb vascularity than sCTA. t-MIP CTP can reveal the anatomical information of collaterals more accurately, which is of great importance for NO-CLI patients undergoing cell transplantation. The 1-month vascular volume increase ratio can predict the 3-month prognosis more precisely on this basis.

Deep Venous Arterialization: Background, Patient Selection, Technique, Outcomes and Follow-up, and Future Implementation

Critical limb-threatening ischemia (CLTI) is a severe manifestation of peripheral arterial disease with a highly increased risk for morbidity and mortality that has limited and suboptimal opportunities for treatment, ultimately resulting in major amputation for patients. Deep venous arterialization (DVA) provides a suitable limb salvage option for "no-option" patients facing amputation by introducing an artificial anastomosis between a site of proximal arterial inflow and retrograde venous outflow to deliver tissue perfusion to lower extremity wounds. Because DVAs are employed as a last-resort effort in CLTI patients, it is important to provide updated information on indications for usage, strategies in creating DVA conduits, and discussion of outcomes and expectations for patients undergoing this procedure. Additionally, variations in method, including use of various techniques and devices, are explored. The authors provide an up-to-date review of the literature and discuss pertinent procedural and technical considerations for utilizing DVAs in CLTI patients.

Transcatheter Arterialization of Deep Veins in Chronic Limb-Threatening Ischemia

BACKGROUND

Approximately 20% of patients with chronic limb-threatening ischemia have no revascularization options, leading to above-ankle amputation. Transcatheter arterialization of the deep veins is a percutaneous approach that creates an artery-to-vein connection for delivery of oxygenated blood by means of the venous system to the ischemic foot to prevent amputation.

METHODS

We conducted a prospective, single-group, multicenter study to evaluate the effect of transcatheter arterialization of the deep veins in patients with nonhealing ulcers and no surgical or endovascular revascularization treatment options. The composite primary end point was amputation-free survival (defined as freedom from above-ankle amputation or death from any cause) at 6 months, as compared with a performance goal of 54%. Secondary end points included limb salvage, wound healing, and technical success of the procedure.

RESULTS

We enrolled 105 patients who had chronic limb-threatening ischemia and were of a median age of 70 years (interquartile range, 38 to 89). Of the patients enrolled, 33 (31.4%) were women and 45 (42.8%) were Black, Hispanic, or Latino. Transcatheter arterialization of the deep veins was performed successfully in 104 patients (99.0%). At 6 months, 66.1% of the patients had amputation-free survival. According to Bayesian analysis, the posterior probability that amputation-free survival at 6 months exceeded a performance goal of 54% was 0.993, which exceeded the prespecified threshold of 0.977. Limb salvage (avoidance of above-ankle amputation) was attained in 67 patients (76.0% by Kaplan-Meier analysis). Wounds were completely healed in 16 of 63 patients (25%) and were in the process of healing in 32 of 63 patients (51%). No unanticipated device-related adverse events were reported.

CONCLUSIONS

We found that transcatheter arterialization of the deep veins was safe and could be performed successfully in patients with chronic limb-threatening ischemia and no conventional surgical or endovascular revascularization treatment options. (Funded by LimFlow; PROMISE II study ClinicalTrials.gov number, NCT03970538.).

Cardiovascular Disease Management in the Context of Global Crisis

The outbreak of coronavirus disease 2019 (COVID-19) initiated a pandemic that has deteriorated health care access and thus disadvantaged vulnerable populations [...].

Guillotine Transmetatarsal Amputations With Staged Closure Promote Early Ambulation and Limb Salvage in Patients With Advanced Chronic Limb-Threatening Ischemia

PURPOSE

Transmetatarsal amputation (TMA) with primary closure has long been an option for limb salvage in patients with advanced chronic limb-threatening ischemia (CLTI) with extensive tissue loss of the forefoot. However, TMA healing and closure techniques are challenging, specifically in high-risk patients. Guillotine transmetatarsal amputations (gTMA) with staged closure may provide an alternative treatment in this population. We report long-term outcomes of such technique.

MATERIALS AND METHODS

A single-center retrospective cohort study of CLTI patients undergoing gTMA between 2017 and 2020 was performed. Limb salvage, wound healing, and survival rates were quantified using Kaplan-Meier (KM) analysis. Multivariate regression was used to identify the effect of patient characteristics on the outcomes.

RESULTS

Forty-four gTMA procedures were reviewed. Median follow-up was 381 (interquartile range [IQR], 212-539.75) days. After gTMA, 87.8% (n=36) of the patients were able to ambulate after a median interval of 2 (IQR, 1-3) days. Eventual coverage was achieved in a personalized and staged approach by using a combination of skin substitutes (88.6%, n=39) ± split thickness skin grafts (STSG, 61.4%, n=27). KM estimates for limb salvage, wound healing, and survival were 84.1%, 54.5%, and 88.6% at 1 year and 81.8%, 63.8%, and 84.1% at 2 years. Wound healing was significantly associated with STSG application (p=0.002, OR=16.5, 95% CI 2.87-94.81).

CONCLUSION

gTMA resulted in high limb salvage rates during long-term follow-up in CLTI patients. Adjunctive STSG placement may enhance wound healing at the gTMA site, thus leading to expedited wound closure. Surgeons may consider gTMA as an alternative to reduce limb loss in CLTI patients at high risk of major amputation.

CLINICAL IMPACT

Currently, the clinical presentation of CLTI is becoming more complex to deal with due to the increasing comorbidities as the society becomes older. The data shown in this article means for clinicians that when facing diffused forefoot gangrene and extensive tissue loss, limb preservation could still be considered instead of major amputation. Guillotine transmetatarsal amputations in the setting of an aggressive multidisciplinary group, can be healed by the responsibly utilization of dermal substitutes and skin grafts leading to the preservation of the extremity, allowing mobility, avoiding of sarcopenia, and decreasing frailty. This will equate to maintenance of independent living and preservation of lifespan.

Duplex and Angiographic-Assisted Evaluation of Outcomes of Endovascular Embolization after Surgical Deep Vein Arterialization for the Treatment No-Option Critical Limb Ischemia Patients

OBJECTIVE

To report early and mid-term outcomes of the arterialization of the deep venous system in no-option critical limb-threatening ischemia (CLTI) using duplex ultrasound and angiographic evaluation to improve limb perfusion.

METHODS

A single-center prospective study of patients with no-option CLTI treated with hybrid surgical arterialization of the deep venous circulation and staged endovascular embolization of the venous collateral. Embolization was performed using a controlled-release spiral, within two weeks after bypass surgery. Patients were assessed for clinical status, wound healing, median transcutaneous partial pressure of O₂ (TcPO₂), and post-operative duplex ultrasound evaluating peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) to assess foot perfusion and bypass features. Primary endpoint analysis was primary technical success, limb salvage, patency rates, and clinical improvement. Secondary endpoints were 30-day and long-term mortality, major cardiovascular events (MACE), including myocardial infarction or stroke, and serious adverse events (SAE).

RESULTS

Five patients with no-option CLTI were treated at our center using the hybrid deep vein arterialization technique. Clinical stage was grade 3 in one patient and grade 4 in the remaining four. Mean age was 65.8 years (range 49-76 years), and two patients were affected by Buerger's disease. Primary technical success was achieved in all patients, and all the bypasses were patent at the angiographic examination. At 30-day and at average follow-up of 9.8 months (range 2-24 months), mortality, major cardiovascular events (MACE), and serious adverse events (SAE) were not reported, with a primary patency and limb salvage rates of 100%. Three patients required minor amputation. Clinical improvement was demonstrated in all patients with granulation, resolution of rest pain, or both. Median TcPO₂ values rose from 10 mm Hg (range 4-25) before the procedure to 35 (range 31-57) after surgery, and to 59 mm Hg (range 50-76) after the staged endovascular procedure.

CONCLUSIONS

In our initial experience, the arterialization of the deep venous circulation, with subsequent selective embolization of the venous escape routes from the foot, seems a feasible and effective solution for limb salvage in patients with no-option CLTI and those in the advanced wound, ischemia, and foot infection (WIfI) clinical stage.

Autologous Stem Cells Transplantation for No-Option Angiitis-Induced Critical Limb Ischemia: Recurrence and New Lesion

Although satisfying outcomes have been demonstrated in terms of autologous stem cell transplantation in the treatment of angiitis-induced critical limb ischemia (AICLI), few studies have systematically reported the recurrence conditions. In the current study, we aimed to investigate recurrence conditions of a relatively large AICLI cohort in our center during a long-term follow-up period. From May 2009 to August 2020, 181 patients with AICLI received peripheral blood mononuclear cells (PBMNCs) or purified CD34+ cells (PCCs) transplantation. The main outcomes included recurrence and new lesions. Patient demographic data, ischemic limb characteristics, interventional characteristics, etc., were identified and analyzed. A logistic multivariable regression was performed to identify the independent risk factors for recurrence by a stepwise selection of variables. One hundred forty-eight patients were enrolled in this study. The mean follow-up period was 62.3 ± 37.4 months (range 12-144 months). The 5- and 10-year recurrence-free rates were 88.5% (95% confidence interval [CI] 3.1%-82.6%) and 71.7% (95% CI 7.6%-58.2%), respectively. The 5- and 10-year new lesion-free rates were 93.2% (95% CI 2.2%-89.0%) and 91.7% (95% CI 2.7%-86.6%), respectively. The finding of multiple limbs involved (OR 1.322 95% CI 1.123-12.549, P = .036) and ischemia relief period ≥5 months (OR 3.367 95% CI 1.112-10.192, P = .032) were demonstrated to be independent risk factors for recurrence in patients with AICLI who underwent cell transplantation. For patients with AICLI who responded to cell transplantation, the durability of this therapy was satisfactory, with 5- and 10-year recurrence-free rates of 88.5% and 71.7%, respectively. Multiple limbs involved at admission and ischemia relief period ≥5 months were demonstrated to be independent risk factors for recurrence after transplantation.

Eligibility of Patients with Chronic Limb Threatening Ischemia for Deep Venous Arterialization

OBJECTIVES

Percutaneous deep venous arterialization (pDVA) has emerged as a new modality for limb salvage in patients with chronic limb threatening ischemia (CLTI) and no standard option for revascularization. The proportion of patients facing major amputation that are eligible for this technology remains unknown. This study aims to provide a real-life estimate of patient eligibility for pDVA to reduce major amputations.

METHODS

Electronic medical records of 100 consecutive patients with peripheral arterial disease (PAD) who underwent major amputation of 106 limbs were reviewed. Angiograms performed ≤6 months before amputation were assessed by two vascular surgeons. Disease severity was categorized using the Global Limb Anatomic Staging System and patients were classified as ideal, possible, or not candidates for pDVA. Ideal candidates had ≥1 patent tibial artery, no target in the foot, and no proximal disease. Possible candidates had ≥1 patent tibial artery with PAD, no target in the foot, and proximal disease amenable to endovascular therapy. Patients were not eligible if there was no patent tibial artery, extensive PAD, or an arterial target in the foot for bypass.

RESULTS

Of 106 limbs reviewed, 35 (33%) did not undergo angiography ≤6 months before amputation because of infection (n=14), advanced tissue loss (n=10), failed revascularizations (n=8), advanced limb ischemia (n=2), and refusing revascularization (n=1). Thus, 69 lower extremity angiograms (2 incomplete excluded) in 68 patients were analyzed. 15 patients with 16 limbs (23.2%) were identified as candidates for pDVA (ideal=7, possible=9). There were no differences in demographics between the two groups, but candidates for pDVA were less likely to have hyperlipidemia and congestive heart failure than those who were not candidates. pDVA candidates underwent significantly fewer interventions prior to major amputation compared to patients who were not candidates (1.50 ± 0.73 vs 2.61 ± 2.57, p=0.007). Angiographically, patients who were pDVA candidates had significantly higher Inframalleolar GLASS grades (1.81 ± 0.40 vs 0.86 ± 0.41, p<0.0001) but lower Femoropopliteal Glass grades (0.73 ± 1.10 vs 2.43 ± 1.71, p<0.0001) than patients who were not candidates. There was no significant difference in GLASS stage between these two groups (p=0.368). After mean follow-up of 48 months, there was no difference in mortality between both groups (40% vs 32.1%, p=0.567).

CONCLUSION

Among patients considered for revascularization, 23.2% had favorable angiography and 14.7% could have benefited for pDVA as a new therapeutic modality for limb salvage. 33% of major amputations were performed for clinically-deemed unsalvageable CLTI.

Return to work after cell transplantation in patients with angiitis-induced critical limb ischaemia and factors related: a single-centre retrospective cohort study

Background

Angiitis-induced critical limb ischaemia (AICLI) patients, who are usually young and have a high amputation rate, always lose their ability to return to the labour force. Return to work (RTW) not only indicates patients’ physical health, showing that they could undertake the work, but also demonstrates their psychological well-being. While cell transplantation showed satisfactory efficacy in limb salvage, few studies of AICLI patients’ RTW after transplantation have been reported.

Methods

From May 2009 to May 2021, AICLI patients who underwent cell transplantation and completed no less than 12 months of follow-up were retrospectively enrolled. The primary endpoint was RTW. Patient demographics and characteristics of the ischaemic limbs were reviewed to analyse independent risk factors for RTW.

Results

A total of 171 AICLI patients (170 males) were enrolled with a mean age of 41.9 ± 9.6 years (range: 20–57 years). The 12-month and 24-month RTW cumulative rates were 69.4% (95% confidence interval [CI] 61.6–75.6%) and 70.1% (95% CI 62.3–76.2%), respectively. Age < 40 years (odds ratio [OR] 2.659, 95% CI 1.138–6.719) and preoperative occupation as a mental worker (OR 8.930, 95% CI 2.665–42.847) were identified as independent protective factors for RTW. Perioperative limb infection with ulcer or gangrene (OR 0.250, 95% CI 0.075–0.779) was identified as an independent risk factor.

Conclusion

AICLI patients who underwent cell transplantation usually had a satisfactory midterm RTW cumulative rate. AICLI patients < 40 years old with preoperative occupation as mental workers were more likely to return to work. Prevention of limb infection during the perioperative period is of great significance to RTW.

The peripheral blood mononuclear cells versus purified CD34+ cells transplantation in patients with angiitis-induced critical limb ischemia trial: 5-year outcomes and return to work analysis-a randomized single-blinded non-inferiority trial

Backgrounds

Patients with AICLI constitute a considerable proportion of NO-CLI patients and cannot be treated with surgical or endovascular treatment. Although cell therapy has shown satisfactory results in treating AICLI, research comparing the efficacy of treatment with the 2 kinds of cell products is rare. The aim of this study was to report the 5-year outcomes of a randomized single-blinded noninferiority trial (Number: NCT 02089828) on peripheral blood mononuclear cells (PBMNCs) and purified CD34⁺ cells (PCCs) transplantation for treating angiitis-induced critical limb ischemia (AICLI).

Methods

A randomized single-blinded non-inferiority trial (Number: NCT 02089828) was performed. Fifty patients were randomized 1:1 to the PBMNCs and PCCs groups. Efficacy outcomes, safety outcomes and patients’ work conditions were analyzed. The primary efficacy outcomes included major amputation and total amputation over 60 months.

Results

During the 60-month follow-up, 1 patient was lost to follow-up, 1 died, and 2 underwent major amputation. The major amputation-free survival rate (MAFS) was 92.0% (95% confidence interval [CI] 82.0%-100.0%) in the PBMNCs group and 91.7% (95% CI 81.3%-100.0%) in the PCCs group (P = 0.980). Compared with the PCCs group, the PBMNCs group had a significantly higher 5-year new lesion-free survival rate (100.0% vs. 83.3% [95% CI 69.7–99.7%], P = 0.039). All patients lost their ability to work before transplantation, and the 5-year cumulative return to work (RTW) rates were 88.0% in the PBMNCs group and 76.0% in the PCCs group (P = 0.085).

Conclusion

The long-term follow-up outcomes of this trial not only demonstrated similar efficacy and safety for the 2 types of autoimplants but also showed a satisfactory cumulative RTW rate in AICLI patients who underwent cell transplantation.

Trial registration: ClinicalTrials.gov, number NCT 02089828. Registered 14 March 2014, https://clinicaltrials.gov/ct2/show/record/NCT02089828.

Comparison of clinical outcomes, including the wound healing rate, between inframalleolar bypass to the pedal artery and that to the pedal branch artery in the modern endovascular era

OBJECTIVE

Inframalleolar (IM) bypass has been reported to demonstrate acceptable patency and limb salvage in chronic limb-threatening ischemia (CLTI) patients. However, wound healing after IM bypass and comparisons between pedal artery (PA) bypass and pedal branch artery (PBA) bypass are lacking.

METHODS

We reviewed prospectively collected data from 208 consecutive patients after IM bypass performed over a period of six years. Patients were divided into two groups based on the distal anastomotic artery: the PA group (dorsal pedis artery or common plantar artery) and the PBA group (medial tarsal, lateral tarsal, medial plantar, and lateral plantar artery). The primary outcome was wound healing, and secondary outcomes included loss of patency and limb and life prognosis.

RESULTS

Of the 208 patients, 174 (74%) had PA bypass, whereas 34 (16%) had PBA bypass. Patients in the PBA group were significantly younger than those in the PA group (69 ± 7 vs. 73 ± 9, P = .03). Although early (30-day) graft failure was more common in the PBA group, late clinical outcomes, including the wound healing rate (79% in the PA group and 84% in the PBA group, P=.74), were similar between the two groups. The Global Limb Anatomic Staging System (GLASS) IM grade (HR, 0.73; 95% confidence interval [CI], 0.58-0.93: P=.006); wound, ischemia, and foot infection (WIfI) wound grade (HR, 0.67; 95% CI, 0.51-0.89: P<.01); and WIfI foot infection grade (HR, 0.79; 95% CI, 0.65-0.96: P=.02) were independent predictors of wound healing.

CONCLUSIONS

The current study revealed that wound healing in patients following PBA bypass was acceptable and comparable to that following PA bypass. In the modern era, including high prevalence of infrapopliteal angioplasty, our results could provide useful information to clinicians in actual clinical settings. Moreover, PBA bypass may be an alternative revascularization procedure to avoid major amputation when the pedal artery is occluded, such as in the GVG IM P2 grade. Prospective multicenter larger studies are warranted to confirm the findings of this study and to compare PBA bypass and IM EVT in anatomical "no-option" CLTI.

A review of percutaneous deep vein arterialization for the treatment of nonreconstructable chronic limb threatening ischemia

Peripheral arterial disease is estimated to affect more than 200 million people worldwide with some patients progressing to chronic limb threatening ischemia (CLTI). Patients with CLTI have extremely high rates of amputation and associated increases in morbidity and mortality. There is a subset of patients with CLTI that have no available options for revascularization due to factors such as the absence of distal target vessels or adequate conduit for surgical revascularization. Percutaneous deep vein arterialization can be used in patients with nonreconstructable CLTI. In this review article, we discuss patient selection, methods, and techniques of deep vein arterialization. In addition, results from studies evaluating the use of percutaneous deep vein arterialization, such as the Alkmaar (The Netherlands), Leipzig (Germany), Paris (France), and Singapore (ALPS) multicenter center study and the prospective, multicenter, single-arm, early feasibility (PROMISE I) trial, are highlighted. These results have been encouraging with improved rates of limb salvage and wound healing reported, suggesting percutaneous deep vein arterialization may be beneficial in treating patients with CLTI.

Deep Venous Arterialization for Chronic Limb Threatening Ischemia in Atherosclerosis Patients - A meta-analysis

BACKGROUND

Venous arterialization is an upcoming and novel alternative in chronic limb threatening ischemia (CLTI) patients in the absence of standard revascularization options. The aim of this study is to systematically review and analyze outcomes of venous arterialization.

STUDY DESIGN

A systematic literature search was performed in 5 databases using the PRISMA methodology. Inclusion criteria were English language original research papers on CLTI patients treated with venous arterialization.

EXCLUSION CRITERIA

absence of CLTI due to atherosclerosis, duplicate study or reporting of patients, meeting abstract only. Quality and risk of bias were evaluated. Meta-analysis was performed using random effects model on articles that have a sample size of equal or greater than 10.

RESULTS

Twelve studies included 442 patients that underwent treatment for 445 limbs (374 patients and 377 limbs underwent venous arterialization while remainder underwent traditional bypass and served as control subjects). Average age was 66 [18 studies, range 37-91 years], 68% were male [271/366, 15 studies] and 67% diabetic [271/406, 16 studies]). Most limbs (88%, 352/398, 16 studies) had tissue loss. Pooled 30-day mortality was 3.7% (95%-confidence interval [CI] 0.8-6.6%), 30-day morbidity was 15.5% (95%-CI 3.2-27.8%), 30-day major adverse cardiovascular event was 5.2% (95%-CI 1.7-8.6%) and 30-day major adverse limb event was 16.7% (95%-CI 1.5-31.9%). Pooled 1-year limb-salvage rate was 79.0% (95%-CI 68.7-90.7) and 1-year survival rate was 85.7% (95%-CI 76.2-96.4). Studies quality varied significantly across studies.

CONCLUSION

Venous arterialization has an acceptable a 1-year limb salvage rate of 79%, however, this is based on low levels of evidence. More randomized controlled trials or high-quality cohort studies are needed to further define the effectiveness of this procedure for CLTI.

CIRSE Standards of Practice on Below-the-Knee Revascularisation

The CIRSE Standards of Practice Committee established a writing group that was tasked with producing up-to-date recommendations for performing below-the-knee revascularisation, taking into account data on novel techniques, devices, and long-term outcomes that have emerged over the last decade. CIRSE Standards of Practice documents are not clinical practice guidelines or systematic reviews of the literature. This document is not intended to impose a standard of clinical patient care but recommends a reasonable approach to and best practices for performing below-the-knee revascularisation.

Percutaneous Saphenous Vein Arterialization

PURPOSE

In patients with no-option critical limb-threatening ischemia, venous foot arterialization can be considered the last chance before major amputation. Up until now, a really significant limitation of endovascular arterialization compared with surgery was the possibility to obtain arterial flow into the foot only through the deep plantar network.

TECHNIQUE

Two 5-mm snares are placed: one in the proximal tibial artery and the other in the great saphenous vein. After passing through these snares with a needle and a guidewire and closing the snares, the guidewire is pulled through the proximal arterial sheath and the distal venous sheath. Thus, the arterial-venous connection is created. A covered stent is, then, placed between the artery and the vein to avoid leakage.

CONCLUSIONS

Based on our knowledge, this is the first described totally percutaneous arterialization of the superficial dorsal venous foot system, through reverse flow in the great saphenous vein.

PROMISE I early feasibility study of the LimFlow System for percutaneous deep vein arterialization in no-option chronic limb-threatening ischemia 12-month results

OBJECTIVE

We report the 6 and 12-month outcomes of the PROMISE I early feasibility study (EFS) after treatment of no-option chronic limb-threatening ischemia (CLTI) with percutaneous deep vein arterialization (pDVA) using the LimFlow System.

METHODS

Thirty-two no-option CLTI patients, previously offered major amputation, were enrolled in this single-arm EFS of the LimFlow pDVA System. No-option CLTI was defined as being ineligible for surgical or endovascular arterial revascularization. Patients were assessed for clinical status, pain, wound healing, and duplex ultrasound at 30 days, 6 months, and 12 months post-treatment. Primary endpoint analysis was amputation-free survival (AFS) at 30 days and 6 and 12 months. AFS was defined as freedom from above-ankle amputation of the index limb and freedom from all-cause mortality. Secondary endpoints evaluated included technical success of the procedure, and wound healing at 6 and 12 months.

RESULTS

Of 32 enrolled patients, 31 (97%) were successfully treated with the LimFlow System at the time of the procedure, and 2 (6.3%) were lost to follow-up. The 30-day, 6-month, and 12-month AFS rates were 91%, 74%, and 70% respectively. Wound healing status of fully healed or healing was 67% at 6-months, and 75% at 12-months. Reintervention was performed in 16 patients (52%) with 14 (88%) of the maintenance reinterventions occurring within the first three months. The majority of reinterventions, 12 (75%), involved the arterial inflow tract proximal to the stented LimFlow circuit, and no in-stent stenoses were determined to have been the cause of reintervention.

CONCLUSIONS

The LimFlow pDVA System was utilized in treating no-option patients with CLTI. High technical success rate was observed, with a significant percentage of patients surviving free of major amputation at 12 months. These results suggest early safety and provide an initial assessment of the efficacy of the LimFlow pDVA System which supports the expansion of carefully executed studies to determine whether this is a viable option that can be used in this critically disadvantaged and growing patient population.

Three-year outcomes of peripheral blood mononuclear cells vs purified CD34+ cells in the treatment of angiitis-induced no-option critical limb ischemia and a cost-effectiveness assessment: A randomized single-blinded noninferiority trial

For patients with angiitis-induced critical limb ischemia (AICLI), cell transplantation, such as purified CD34+ cells (PCCs) and peripheral blood mononuclear cells (PBMNCs), is gradually being used as a promising treatment. This was the first randomized single-blinded noninferiority trial (number: NCT02089828) specifically designed to evaluate the therapeutic efficacies of the transplantation of PCCs vs those of PBMNCs for the treatment of AICLI. We aimed to compare the mid-term safety and efficacy between the two groups and determine their respective advantages. From April 2014 to September 2019, 50 patients with AICLI were equally allocated to the two groups, except for 1 lost patient, 1 amputee, and 1 patient who died of heart disease. The other 47 patients completed the 36-month follow-up. The endpoints were as follows: major amputation-free survival and total amputation-free survival at 6 months, which were 96.0% and 84.0% in the PBMNCs group and 96.0% and 72.0% in the PCCs group, respectively. These rates remained stable at 12, 24, and 36 months. The PCCs group had a significant higher probability of rest pain relief than the PBMNCs group, whereas earlier significant improvements in the Rutherford classification were observed in the PBMNCs group. Accordingly, PCCs would be preferred for patients with significant pain, whereas PBMNCs may be a good option for patients with two or more critically ischemic limbs. Concerning cost-effectiveness, PCCs are not more cost-effective than PBMNCs. These outcomes require verification from long-term trials involving larger numbers of patients.

Percutaneous deep venous arterialization at femoropopliteal segment for unhealed amputated stump ulcer after below the knee amputation

Efficacy of percutaneous deep venous arterialization (pDVA) has been reported for patients with no-option chronic limb threatening ischemia. To date, the procedure has been limited for below the knee/below the ankle occlusive disease. The present report describes the pDVA performed at a femoropopliteal segment for a patient with a stump complication after below the knee amputation. The patient was a 70-year-old male who had a history of endovascular treatment in the right superficial femoral artery (SFA) and below knee amputation 6 years before. He had an unhealed ulcer at the amputated stump for 3 years. Computed tomography angiography demonstrated occluded right SFA, with a stenotic popliteal artery. Revascularization was considered unfeasible due to the absence of run off vessels. In order to improve the perfusion at the ulcer, pDVA was performed at the distal SFA level, bridging SFA and femoral vein using stent grafts. The final angiogram demonstrated the revascularized SFA connecting to popliteal vein with a brisk flow. After pDVA, the stump ulcer improved and the stent grafts were kept patent after 6 months of the procedure. pDVA at the SFA level was technically feasible and could be a useful approach for stump complication after below knee amputation.

Prediction of successful guidewire crossing of below-the-knee chronic total occlusions using a Japanese scoring system

OBJECTIVE

To develop a scoring system that can adequately predict a successful guidewire crossing (S-GC) of below-the-knee (BTK) chronic total occlusions (CTOs) in angiographic evaluation.

METHODS

A retrospective, multicenter, nonrandomized study examined 448 consecutive BTK CTOs in 299 patients treated with endovascular therapy in seven Japanese medical centers from April 2012 to April 2020. The cohort was classified into two groups: an S-GC group and a failed guidewire crossing group.

RESULTS

The final logistic regression model created by a backward stepwise multivariate logistic regression model included five variables: "No outflow of the target vessel," "CTO length ≥200 mm," "Reference vessel diameter <2.0 mm," "Calcification at the proximal entry point," and "Blunt type at entry point." Optimisms were adjusted using 1000 bootstrap samples with replacement and candidate's risk score models developed according to optimism-adjusted correlation coefficients of risk factors. Choosing the best model as the Japanese-BTK (J-BTK) CTO score by comparing the optimism-adjusted area under receiver-operating characteristic curves it was decided to assign one point to "Blunt type at the proximal entry point," one point to "Calcification at the proximal entry point," one point to "Reference vessel diameter <2.0 mm," one point to "CTO length ≥200 mm," and two points to "No outflow of the target vessel." This rule was then used to categorize BTK CTOs into four grades with varying probabilities of S-GC: grade A (J-BTK CTO score of 0 and 1), grade B (score of 2 and 3), grade C (score of 4 and 5), and grade D (score of 6). Rates of S-GC in each grade (grades A, B, C, and D) were 97.3%, 76.8%, 19.3%, and 0%, respectively. Lesions categorized as grade C or D have a lower chance of S-GC. Internal validation was performed using the Hosmer-Lemeshow test (P = .99).

CONCLUSIONS

The J-BTK CTO score predicts the probability of an S-GC of BTK CTOs and stratifies the difficulty of endovascular therapy for BTK CTOs in angiographic evaluation.

Pain Management in People with Diabetes-Related Chronic Limb-Threatening Ischemia

Management of neuropathic pain in people with diabetes has been widely investigated. However, little attention was paid to address ischemic-related pain in patients with diabetes mellitus who suffered from chronic limb-threatening ischemia (CLTI), the end stage of lower extremity arterial disease (LEAD). Pain management has a tremendous influence on patients' quality of life and prognosis. Poor management of this type of pain owing to the lack of full understanding undermines patients' physical and mental quality of life, which often results in a grim prognosis, such as depression, myocardial infarction, lower limb amputation, and even mortality. In the present article, we review the current strategy in the pain management of diabetes-related CLTI. The endovascular therapy, pharmacological therapies, and other optional methods could be selected following comprehensive assessments to mitigate ischemic-related pain, in line with our current clinical practice. It is very important for clinicians and patients to strengthen the understanding and build intervention strategy in ischemic pain management and possible adverse consequence.

Percutaneous Deep Foot Vein Arterialization IVUS-Guided in No-Option Critical Limb Ischemia Diabetic Patients

PURPOSE

To report our clinical experience with IVUS-guided percutaneous deep vein arterialization (pDVA) to treat chronic critical limb ischemia (cCLI) patients with no-endovascular or surgical options approach due to creation of an arteriovenous fistula (AVF).

MATERIALS AND METHODS

In a 2 years period, 14 no-option cCLI patients were treated with percutaneous deep vein arterialization (pDVA) by creating an AVF with a IVUS-guided system between posterior tibial artery and its satellite deep vein. Technical success was defined as successful AVF creation and venous perfusion of the wound site. Patients' characteristics, procedure details, mortality and wound outcomes were assessed prospectively.

RESULTS

Successful pDVA was successfully performed in all patients (mean age 82 years) without any procedural complications. Clinical improvement was achieved in all patients with resolution of rest pain, tissue formation of granulation tissue or both; only 3 major amputations were performed within the study period with a limb salvage rate of 78%. Median wound healing time was 4.8 months.

CONCLUSION

pDVA is a safe and feasible revascularization technique alternative in no-option cCLI patients.

A Review and Proposed Classification System for the No-Option Patient With Chronic Limb-Threatening Ischemia

A growing, but poorly defined subset of patients with chronic limb-threatening ischemia (CLTI) have "no option" for revascularization. One notable subgroup includes patients with severe ischemia and advanced pedal artery occlusive disease, termed "desert foot," who are at high risk for major amputation due to a lack of conventional revascularization options. Although new therapies are being developed for no-option patients with desert foot anatomy, this subgroup and the broader group of no-option patients are not well defined, limiting the ability to evaluate outcomes. Based on a systematic review, a classification of the no-option CLTI patient was constructed for use in clinical practice and studies. Several no-option conditions were identified, including type I-severe and pedal occlusive disease (desert foot anatomy) for which there is no accepted method of repair; type II-lack of suitable venous conduit for bypass in the setting of an acceptable target for bypass; type III-extensive tissue loss with exposure of vital structures that renders salvage impossible; type IV-advanced medical comorbidities for which available revascularization options would pose a prohibitive risk; and type V-presence of a nonfunctional limb. While type I and type II patients may have no option for revascularization, type III and type V patients have wounds, infection, comorbidities, or functional status that may leave them with few options for revascularization. As treatment strategies continue to evolve and novel methods of revascularization are developed, the ability to identify no-option patients in a standardized fashion will aid in treatment selection and assessment of outcomes.

Volume Flow and Peak Systolic Velocity of the Arteriovenous Circuit in Patients after Percutaneous Deep Venous Arterialization

Percutaneous deep venous arterialization (pDVA) is a developing technique for limb salvage in patients with chronic limb-threatening ischemia by creating an arteriovenous (AV) circuit. After pDVA, patency of the AV circuit is evaluated using duplex ultrasound (DUS) imaging. Peak systolic velocity (PSV) and volume flow (VF) values for maintaining a patent AV circuit are undefined; therefore, guidance about when a reintervention should be performed is lacking. The objective of this study was to interpret post-pDVA PSV and VF values in relation to AV circuit preservation. This was performed by analyzing DUS results of 22 post-pDVA patients. A total of 670 PSV and 623 VF measurements were collected. A PSV value of ≤55 cm/s and a VF value of ≤195 mL/min were found predictive for failure. The reliability of PSV and VF measurements in patent AV-circuits was good (intraclass correlation coefficient; PSV, 0.85; VF, 0.88). In conclusion, this study is the first to analyze DUS measurements in post-pDVA patients and showed that DUS can be used to anticipate for failure. The thresholds found can be used to help interpret DUS measurements in post-pDVA patients. More research in a larger patient population is needed to prospectively validate these thresholds.

New Innovations and Devices in the Management of Chronic Limb-Threatening Ischemia

As the number of patients afflicted by chronic limb-threatening ischemia (CLTI) continues to grow, new solutions are necessary to provide effective, durable treatment options that will lead to improved outcomes. The diagnosis of CLTI remains mostly clinical, and endovascular revascularization remains mostly balloon-based. Multiple innovative techniques and technologies are in development or in early usage that may provide new solutions. This review categorizes areas of advancement, highlights recent developments in the management of CLTI and looks forward to novel devices that are currently under investigation.

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

Purpose: To evaluate the midterm results of patients suffering from no-option chronic limb-threatening ischemia (CLTI) treated with a dedicated system for percutaneous deep venous arterialization (pDVA). Materials and Methods: Thirty-two consecutive CLTI patients (mean age 67±14 years; 20 men) treated with pDVA using the Limflow device at 4 centers between 11 July 2014 and 11 June 2018 were retrospectively analyzed. Of all patients, 21 (66%) had diabetes, 8 (25%) were on immunosuppression, 4 (16%) had dialysis-dependent renal failure, 9 (28%) had Rutherford category 6 ischemia, and 25 (78%) were deemed at high risk of amputation. The primary outcome was amputation-free survival (AFS) at 6 months. Secondary outcomes were wound healing, limb salvage, and survival at 6, 12, and 24 months. Results: Technical success was achieved in 31 patients (96.9%). The median follow-up was 34 months (range 16-63). At 6, 12, and 24 months, estimates were 83.9%, 71.0%, and 67.2% for AFS, 86.8%, 79.8% and 79.8% for limb salvage, and 36.6%, 68.2%, and 72.7% for complete wound healing, respectively. Median time to complete wound healing was 4.9 months (range 0.5-15). The DVA circuit occluded during follow-up in 21 patients; the median time to occlusion was 2.6 months. Reintervention for occlusion was performed in 17 patients: 16 because of unhealed wounds and 1 for a newly developed ulcer. Conclusion: This study represents the largest population of patients with no-option CLTI treated with pDVA using the LimFlow device with midterm results. In this complex group of patients, pDVA using the LimFlow device has been shown to be feasible, with a high technical success rate and AFS at 6 up to 24 months coupled with wound healing. In selected patients with no-option CLTI, pDVA could be a recommended treatment to prevent amputation and heal wounds.