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

Abstract

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 who 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. Electronic medical records of 100 consecutive patients with peripheral arterial disease (PAD) who underwent major amputation of 106 limbs were reviewed. Angiograms performed ≤6months before amputation were assessed by two vascular surgeons. Disease severity was categorized using the Global Limb Anatomic Staging System (GLASS) 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. Of 106 limbs reviewed, 35 (33%) did not undergo angiography ≤6months 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. A total of 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. The pDVA candidates underwent significantly fewer interventions before 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 48months, there was no difference in mortality between both groups (40% vs. 32.1%, P=0.567). 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.