Distal Venous Arterialization Research Articles

Catheter-directed thrombolysis for critical hand ischemia with failed distal venous arterialization.

Catheter-directed thrombolysis for critical hand ischemia with failed distal venous arterialization.

Vena saphena magna in situ arterializacija gebstint koją: atvejo aprašymas

[straipsnis ir santrauka anglų kalba]

Microvascular in-vivo Analysis of Retrograde Venous Arterialization of Ischemic Skeletal Muscle

Objective: Nearly 20% of patients with critical limb ischemia will not be suitable for arterial bypass due to distal small vessel occlusion, and venous arterialization of the distal venous bed might be a valuable surgical option. This study demonstrates the in-vivo microcirculatory effects of this type of intervention. Methods: Using intravital video microscopy, the authors studied the distal skeletal microcirculatory characteristics following venous arterialization of critical hindlimb ischemia in the rat. 25 Wistar rats underwent proximal ligation of the femoral arteries followed by venous arterialization carried out by anastomosing the saphenous vein to the femoral artery using microsurgery techniques. Microcirculatory hemodynamic conditions of the soleus muscle were observed under normal, ischemic, and arterialized conditions. Fluorescein-labeled red cells were used to measure red cell velocities (Vrbc) at the capillaries, and acridine orange injections used to stain endothelial cell nuclei to measure microcirculatory diameters, and leukocyte nuclei to measure leukocyte adhesion. Laser Doppler Perfusion (LDP) units at the distal limb were measured continuously throughout the procedure. Results: Proximal femoral arterial ligation resulted in drastic reductions in LDP and Vrbc. Following distal venous arterialization, LDP returned to an average of 41% of baseline. Vrbc returned to near baseline values in 70% of the capillaries. Flow at the capillary and venular system showed frequent reversals and great variations in velocities. Venules and venu-venular anastomoses diameters increased by 50%. There was immediate macromolecular tracer leakage and leukocyte activation was significantly increased in both ischemic and arterialized groups (15 cells vs 156 and 178 cells respectively). Conclusion: Venous arterialization may provide an improvement in microcirculatory velocities but is accompanied by microcirculatory injury and dysfunction in the acute phase. These results suggest that mechanisms besides microcirculatory hemodynamics play a role in the overall picture of clinical effectivity of the procedure. Key words: Retrograde venous arterialization, ischemic skeletal muscle

Comparative Study of Venous Arterialization and Pedal Bypass in a Patient Cohort with Critical Limb Ischemia

Patients with critical limb ischemia (CLI) have a poor life expectancy, and aggressive revascularization is accepted as a means to maintain their independence in the end stage of life. The goal of this case-control study was to evaluate the clinical outcome of distal venous arterialization and compare this with pedal bypass surgery in patients with CLI, and to identify potential risk factors that could be used to effectively identify patients at high risk of graft occlusion and amputation. A retrospective cohort of patients was treated for CLI using venous arterialization or pedal bypass between 2007 and 2012. Kaplan-Meier and Cox regression analyses were used to evaluate predictors for limb salvage and patency. In 40 patients with CLI, 21 venous arterializations and 19 pedal bypasses were performed. In the venous arterialization group, early occlusion was 15%, 1-year patency was 71%, and limb salvage was 53%. In the PB group, early occlusion was 23%, one-year patency was 75% and limb salvage was 47%. The only independent risk factor for limb salvage in multivariate analysis was bypass occlusion (P<0.001). Limb salvage after venous arterialization was equal to limb salvage after pedal bypass surgery in this clinical comparative study.

Early results from an angiosome-directed open surgical technique for venous arterialization in patients with critical lower limb ischemia

BackgroundPatients with critical lower limb ischemia without patent pedal arteries cannot be treated by the conventional arterial reconstruction. Venous arterialization has been suggested to improve limb salvage in this subgroup of patients but has not gained wide acceptance. We report our early experience after implementing deep and superficial venous arterialization of the lower limb.Materials and methodsTen patients with critical ischemia and without crural or pedal arteries available for conventional bypass surgery or angioplasty were treated with distal venous arterialization. Inflow was from the most distal unobstructed segment. Run-off was the dorsal pedal venous arch (n=5), the dorsal pedal venous arch and a concomitant vein of the posterior tibial artery (n=3), or the dorsal pedal venous arch and a concomitant vein of the common plantar artery (n=2) depending on the location of the ischemic lesion. Venous valves were destroyed using antegrade valvulotomes, guide wires, knob needles, or retrograde valvulotomes via an extra incision.ResultsSeven of the operated limbs were amputated after 23 (1–256) days (median [range]). The main reasons for amputation were lack of healing of either the original wound, of incisional wounds on the foot, or persisting pain at rest. In three cases, the bypass was open at the time of amputation. Two patients experienced complete wound healing after 231 and 342 days, respectively. By the end of follow-up, the last patient was ambulating with slow wound healing but without pain 309 days after surgery.ConclusionVenous arterialization may be used as a treatment of otherwise unsalveable limbs. The success rate is, however, limited. Technical optimization of the technique is warranted.

Distal Venous Arterialization and Reperfusion Injury: Focus on Oxidative Status

In patients with unreconstructable arterial occlusive disease distal venous arterialization (DVA) seems to be a promising option in the treatment. The goals of this prospective study were to assess clinical efficiency and possible impact of DVA on tissue damage by estimating oxidative status of patients with critical limb ischemia treated with this procedure. The subjects were 60 randomized patients: 30 were undergoing DVA and 30 were treated with antiaggregation therapy. During the mean follow-up period (6.13 ± 4.32 months for DVA vs. 6.74 ± 0.5 months for antiaggregation therapy) survival (p < 0.01), limb salvage (p < 0.001), pain relief (p < 0.001) and wound healing (p < 0.001) rates were significantly different between the two groups of patients in favor of the DVA group. Ten minutes after declamping we observed a decreasing trend in the lactate level in the blood of the deep venous system (p < 0.001). Also, on postoperative day 7 digital systolic pressure and digital-brachial index were higher than before the operation (p < 0.001). In blood samples collected immediately before and successively at 1, 3, 5 and 10 min postoperatively, prooxidative status (thiobarbituric acid reactive substances, O₂^–, H₂O₂ and nitric oxide) and antioxidative enzymes (superoxide dismutase, catalase and glutathione reductase) were determined spectrophotometrically. Using the nonparametric Friedman test, we noted statistically nonsignificant differences (p > 0.05) in values of both prooxidative parameters and enzymes of the antioxidative defense system, before and successively at 1, 3, 5 and 10 min after operation. These results indicate that there was no statistically significant reperfusion injury after revascularization, which could have been expected after this surgical procedure, thus confirming its validity in these patients.

Management of chronic critical lower limb ischemia with no distal run off

Despite advances in vascular and endovascular techniques, 14-20% of patients with chronic lower limb ischemia are not suitable for distal arterial reconstruction due to occlusion of crural and pedal arteries. The aim of this study was to evaluate the outcome of distal venous arterialization (DVA) in treatment of those patients in whom major amputations were decided.This study was conducted in Tanta University Hospital; in the period from April], 2008 to March 31, 2010 on 27 patients with chronic critical/ower limb ischemia with no distal run off. Arteriogram and coloured Duplex were mandatory investigations. Great saphenous vein (GSV) was anastomosed to the superficial femoral artery in 15 patients (55.5%), to the popliteal artery in 9 patients (33.3%) and to the common femoral artery in three patients (11.1%).All DVA procedures were peiformed in situ with destruction of the valves of the GSV using Mills valvulotome. After the first year, limb salvage was achieved in 17 patients (65.4%) with healing of wounds, marked improvement of the rest pain and increased pain free walking distance. Nine patients (34.6%) ended with major amputation. As a conclusion, DVA could be considered as a promising method in treatment of chronic critically ischemic limb with no distal run off before jumping to major amputation.

Early Individual Experience with Distal Venous Arterialization as a Lower Limb Salvage Procedure

This prospective randomized study reported early results of the treatment of 36 unreconstructable patients with critical lower limb ischemia. The patients were divided into two groups: 12 were treated with distal venous arterialization (DVA) and 24 were conservatively (CT) using antiplatelet drugs. There were seven men and five women with an average age 64.3 ± 9.9 in DVA and 13 men and 11 women with a average age 67.1 ± 10.8 in CT groups of patients. The aim of this study was to estimate the validity of DVA as the limb salvage procedure. During the period of monitoring, morbidity and mortality rates were 50 and 0 per cent at DVA versus a mortality rate in the CT group of 33.3 per cent (P < 0.05). The mean follow-up period for DVA was 4.8 ± 3.9 months (range, 1 to 14 months) versus 4.9 ± 2.4 months (range, 1 to 9 months) for the CT group (P > 0.05). Graft patency was 83.3 per cent with two early graft thromboses. There were significant differences between the two groups in limb salvage (91.7% DVA vs 12.5% CT, P < 0.001), pain relief (75% DVA vs 8.3% CT, P < 0.001), and wound healing rates (77.8% DVA vs 0% CT, P < 0.001). Lactate level in the blood of deep venous system after repeated measuring was significantly decreased after the multivariate analysis of variance method was applied (F = 7.691, P < 0.01). Hemodynamic parameters such as systolic digital pressure and digitobrachial systolic pressure index were increased after revascularization using Student's t test (P < 0.001). The DVA may improve the outcome of the treatment of the patients for whom the conventional bypass procedure mainly was not possible.

Combined Distal Venous Arterialization and Free Flap for Patients with Extensive Tissue Loss

We evaluated the mid-term outcome of distal venous arterialization (DVA) and the role of a combined free flap as a bridgehead for blood supply. In the past 5 years, nine patients with extensive tissue loss and lacking graftable distal arteries underwent DVA. These consisted of four primary DVAs, three combined DVA and free flap procedures, and two adjuvant DVAs for hemodynamically failed distal bypasses. After nine primary DVAs, three redo DVAs were performed for early failure. Etiologies were four Buerger disease and five arteriosclerosis obliterans, including three dialysis patients. Among the nine DVA cases, there were five primary failures: two underwent amputation, two had successful redo DVA, and the remaining one did not require redo DVA. Primary patency, secondary patency, and limb salvage rates were 44.4%, 55.6%, and 77.8%, respectively. The postoperative period was 1-36 months (median 12). Angiography demonstrated DVA was effective in the early period, and development of collaterals or a capillary network from the free flap replaced the DVA function in the intermediate period. DVA can be effective as a procedure for limb salvage in patients without graftable distal arteries, and a combined free flap is effective and functions as a bridgehead for blood supply to the ischemic zone.

Distal venous arterialization for lower limb salvage: angiographic appearances and interventional procedures.

Approximately 14%-20% of patients with critical lower limb ischemia are unsuited for distal arterial reconstruction and face major distal amputation. Distal venous arterialization is a unique procedure in which the venous bed is used as an alternative conduit for perfusion of peripheral tissues. Eighteen patients with stage IV Fontaine critical lower limb ischemia underwent venous arterialization. Preoperative angiographic findings confirmed the absence of any below-knee continuous arterial vessels. The most distal satisfactory artery was used for proximal bypass anastomosis, and venous valves were destroyed with Parsonnet probes, cutting balloons, Fogarty catheters, and valvulotomes under radiologic guidance. All patients underwent intra- and postoperative angiography of the venous grafts and the distal venous bed. Primary and secondary graft patencies were 66% and 72%, respectively, at a mean follow-up of 25 months. The limb salvage rate was 83% overall and 75% at 2-year follow-up. Vascular imaging is essential in selecting and following up patients and in determining the appropriate intraoperative procedure.

Vascular surgical society of great britain and ireland: distal venous arterialization for non-reconstructable arterial disease

BACKGROUND: Despite advances in vascular surgical and interventional radiological techniques, 14-20 per cent of patients with critical lower limb ischaemia will not be suitable for distal arterial reconstruction owing to occlusion of crural and pedal vessels. Following investigation into the venous anatomy of the foot, the disease-free venous bed was used as an alternative conduit for perfusion of peripheral tissues. METHODS: For 22 months, venous arterialization was performed for all patients with non-reconstructable disease but potentially salvageable feet. There were 15 patients; 14 had surgery for chronic ischaemia and one for acute embolization from a popliteal aneurysm after unsuccessful thrombolysis. The inflow vessel was the common femoral artery in 12 and the popliteal artery in three patients. Reversed contralateral long saphenous vein was used in five, a composite graft in three and a polytetrafluoroethylene graft with vein patch in the remaining seven. The distal anastomosis was to the dorsal venous arch (13 cases) and in two to vena comitantes of the posterior tibial vein owing to extensive tissue loss. Various techniques were employed to destroy the valve. RESULTS: Three procedures failed immediately after operation and major amputation was required. The remaining 12 patent grafts were monitored by duplex scan; two required intervention to correct distal anastomotic stenosis by angioplasty and atherectomy (one patient each). The limb salvage rate at 2-22 months of follow-up was 80 per cent. CONCLUSION: Distal venous arterialization is a unique and promising operation which merits further evaluation.