Surgical Deep Vein Arterialization: Adding To The Armamentarium Of Complex Limb Salvage

Abstract

INTRODUCTION AND OBJECTIVES Patients with severe peripheral arterial disease with limited or non-existent arterial runoff, the so-called “desert foot”, challenge efforts at limb preservation. Deep vein arterialization (DVA) involves incorporating a venous target as outflow to achieve revascularization in these complex patients. We report outcomes in an initial series of patients undergoing DVA as a component of surgical bypass. METHODS Over a 2-year period, 10 patients underwent bypass incorporating DVA due to severely disadvantaged runoff using a heparin-bonded ePTFE conduit. Indications for surgery included tissue loss (8) or ischemic rest pain (2) in patients who had failed prior endovascular (3) or surgical (7) revascularization. Inflow arteries for bypass ranged from external iliac to below knee popliteal. Outflow anastomoses incorporated a common ostium AV fistula between anterior tibial (5), posterior tibial (2), peroneal (1) or plantaris pedis (2) arteries and corresponding tibial veins. Prior to anastomotic completion, tibial vein valves were lysed to allow venous arterialization through retrograde flow. Postoperative medical regimen included dual antiplatelet (2), antiplatelet plus anticoagulation (7), or anticoagulation alone (1). RESULTS Primary patency was maintained in 7 of 10 grafts (average of 4.1 months, range 1-18 months). Limb salvage was achieved in 8 of 10 patients (average of 6 months, range 1-18 months). 2 below knee amputations were performed after graft occlusion due to extensive tissue loss and infection, while 1 patient maintained limb salvage despite graft occlusion after successful wound healing. CONCLUSIONS This initial experience describes surgical DVA using a prosthetic conduit in conjunction with an AV fistula at the distal anastomosis in patients with threatened limb loss and severely disadvantaged tibial runoff. Although evidence for long-term efficacy is uncertain, further investigation is warranted as this technique may allow for surgical bypass resulting in limb preservation for patients with no other alternative than amputation. Patients with severe peripheral arterial disease with limited or non-existent arterial runoff, the so-called “desert foot”, challenge efforts at limb preservation. Deep vein arterialization (DVA) involves incorporating a venous target as outflow to achieve revascularization in these complex patients. We report outcomes in an initial series of patients undergoing DVA as a component of surgical bypass. Over a 2-year period, 10 patients underwent bypass incorporating DVA due to severely disadvantaged runoff using a heparin-bonded ePTFE conduit. Indications for surgery included tissue loss (8) or ischemic rest pain (2) in patients who had failed prior endovascular (3) or surgical (7) revascularization. Inflow arteries for bypass ranged from external iliac to below knee popliteal. Outflow anastomoses incorporated a common ostium AV fistula between anterior tibial (5), posterior tibial (2), peroneal (1) or plantaris pedis (2) arteries and corresponding tibial veins. Prior to anastomotic completion, tibial vein valves were lysed to allow venous arterialization through retrograde flow. Postoperative medical regimen included dual antiplatelet (2), antiplatelet plus anticoagulation (7), or anticoagulation alone (1). Primary patency was maintained in 7 of 10 grafts (average of 4.1 months, range 1-18 months). Limb salvage was achieved in 8 of 10 patients (average of 6 months, range 1-18 months). 2 below knee amputations were performed after graft occlusion due to extensive tissue loss and infection, while 1 patient maintained limb salvage despite graft occlusion after successful wound healing. This initial experience describes surgical DVA using a prosthetic conduit in conjunction with an AV fistula at the distal anastomosis in patients with threatened limb loss and severely disadvantaged tibial runoff. Although evidence for long-term efficacy is uncertain, further investigation is warranted as this technique may allow for surgical bypass resulting in limb preservation for patients with no other alternative than amputation.