Venous Arterialization Research Articles

Percutaneous Deep Venous Arterialization by Balloon Angioplasty without Stent Implantation for Patients with Chronic Limb-Threatening Ischemia Undergoing Hemodialysis: A Retrospective Cohort, Single-Center, Single-Arm Study.

This retrospective, single-center study aimed to determine the efficacy of percutaneous deep venous arterialization in patients on hemodialysis with chronic limb-threatening ischemia. Twenty-one consecutive limbs on hemodialysis with chronic limb-threatening ischemia were treated with percutaneous deep venous arterialization using balloon angioplasty following a failed pedal arterial reconstruction between May 2021 and June 2022. An arteriovenous fistula near the ankle joint was created to ensure sufficient venous flow reversal to the pedal veins. In case of occlusion of the tibial artery, a guidewire was advanced (subintimal) to the ankle joint vicinity was technically important. The primary outcome measures were the 6-month complete wound healing and freedom from major amputation rates; the secondary outcome measure was the 6-month amputation-free survival. Occlusion of all pedal arteries was observed in 17 limbs (81.0%). Arteriovenous fistulas were predominantly created at the distal portions of the posterior tibial artery and vein in 18 limbs (85.7%). No extravasation at the fistulas was observed. Re-intervention was required in 16 limbs (76.2%) due to tibial artery or deep vein occlusion. The 6-month complete wound healing rate was 42.9% (nine limbs), with a median healing time of 85 days (interquartile range: 58-151 days). The 6-month freedom from major amputation and amputation-free survival rates were 90.5% (19 limbs) and 61.9% (13 limbs), respectively. Balloon angioplasty without stent implantation for percutaneous deep venous arterialization is promising for improving the complete wound healing and amputation-free survival rates after pedal artery reconstruction failure. Level 3b, retrospective cohort study.

Great Saphenous Vein Arterialization in Patients with Severe Chronic Limb Threatening Ischemia: A Last Resort for Limb Salvage

ObjectiveIn one-fifth of patients with chronic limb-threatening ischemia there are no revascularisation options. In those cases, venous arterialisation could be a last resort for limb salvage. This study examines the clinical outcome of 17 patients, with non-healing wounds (Fontaine 4), who underwent Great Saphenous Vein (GSV) arterialisation leaving the distal saphenous side branches open and avoiding incisions in the lower leg and foot. MethodsIn this retrospective study all the patients who underwent GSV arterialisation between 1 January 2020 and 1 October 2023 were included. During the procedure, a small incision was made in the groin to identify the GSV and SFA. The GSV was detached from the deep venous system, the upper leg side branches were ligated, and the side branches distal to the knee joint were left open to create a pressure drop. Valvulotomy of the GSV down to the foot was performed in all patients. This approach does not necessitate the use of grafts or stents so that a serious infected foot can also be treated. For this study we have analysed the Limb salvage, wound healing, and mobility after treatment and observed pre and postoperative skin oxygenation over a one-year period. ResultsThis intervention resulted in a limb salvage rate of 46% and a secondary patency of 88% after one year in cases where amputation would have otherwise been necessary. Pre- and postoperative TcPO2 measurements indicated a gradual but consistent increase in skin oxygenation in 71% of the patients with a GSV larger than 3mm, underscoring the importance of future patient selection. All patients who successfully received arterialisation showed complete wound healing and improved mobility. ConclusionThis study introduced a promising approach to venous arterialisation in patients with severe CLTI who have no other treatment options, potentially impacting disease burden and quality of life significantly.

Effectiveness of autologous interposition saphenous graft in the creation of proximal arteriovenous fistula: Our initial experience

Abstract: For the individuals with end-stage renal disease, maintenance hemodialysis is a common treatment. When we compare to dialysis catheters or prosthetic grafts, arteriovenous fistula (AVF) is associated with a greater maturation period but a smaller incidence of infections, central venous stenosis, hospitalizations, and mortality. Fistulas mature by a dynamic process which is known as venous arterialization, where the breakdown of elastin and release of nitric oxide promote the functional and structural remodeling of the venous wall, permitting the expansion of venous outflow. Veins made them exposed to the arterial environment at the time of venous grafts and AVFs creation. Successful adaptation of the vein to the arterial flow is the most demanding part for long-term success, identified by venous dilation followed by wall thickening. Arteriovenous fistulas (AVF) and grafts (AV graft) are the commonest form of vascular access used for maintenance of hemodialysis. In general AVF is superior than AV graft in terms of its durability, patency, complication rate and overall survival of patients. But when the calibre of the vein is not satisfactory or length is not adequate to make tension free anastomosis, interposition graft is used. Most commonly used bridging material is polytetrafluoroethylene (PTFE) polymer. In this case, we used an interposition graft of the saphenous vein for making dialysis access on a 38 year old male patient having renal insufficiency and evaluated its efficacy in maintaining flow.

The particularities of connective fibers from the wall of varicose veins extirpated by cryostripping.

The varicose vein affects more than 30% of the general population. Significantly increased rates were noticed in women and older population. From the histopathological point of view, venous arterialization, smooth muscle cell hypertrophy, and hyperplasia are the main changes noticed in varicose vein disease. Some of the main therapeutic methods used in the management of varicose disease are injection sclerotherapy, conservative, surgical, saphenous vein inversion and removal, high saphenous ligation, ambulatory phlebectomy, transilluminated powered phlebectomy, endovascular management, cryostripping. The aim of this study was to evaluate the morphology of connective fibers from the wall of the varicose veins extirpated by cryostripping. The study included 109 samples taken by cryostripping method. Hematoxylin-Eosin, Masson's trichrome, Silver and Orcein staining were applied. The assessment of fibers was made according to score values between 0 and 3. It was found no major structural differences in terms of alterations of collagen fibers induced by the applied surgical procedure. It was noticed duplications and multiplications of the internal elastic lamina, as diffuse and nodular forms. Depletion of elastic fibers at the media was a lesion identified in most of the specimens. The depletion of reticulin fibers correlates with the accumulation of collagen fibers, which partially or completely replace the network in the media and intima. No correlation was found between changes in the reticulin network and the time between prelevation and buffered formalin fixation, the maximum time investigated being five days. The Orcein staining in the venous vessel evaluation panel may be a useful investigation.

A novel approach to deep venous arterialization using WavelinQ EndoAVF technology

A novel approach to deep venous arterialization using WavelinQ EndoAVF technology

Comparison of outcomes of percutaneous deep venous arterialization in multiple practice settings

ObjectiveWe compared the efficacy of percutaneous deep venous arterialization (pDVA) in patients with no-option chronic limb-threatening ischemia in the hospital vs in office-based laboratory (OBL) settings. MethodsA retrospective chart review was performed of all patients who underwent pDVA using off-the-shelf devices from January 2018 to March 2023 in a hospital and an OBL. We identified 73 eligible patients, 41 from a hospital setting (59% male; median age, 72 years; interquartile range, 18 years) and 32 from an OBL setting (59% males; 67 years; interquartile range, 16 years). All eligible patients were deemed to have no-option critical limb ischemia, had at least one patent proximal tibial artery available for the creation of an arteriovenous anastomosis, and were classified as having Rutherford classification IV or higher peripheral arterial disease. Patients were ineligible if classified as Rutherford classification III or lower, had active infection, did not have at least one appropriate venous target, and/or had rapidly progressing wounds requiring immediate major amputation. The primary outcome was major amputation-free survival (AFS). Secondary outcomes included technical success, limb salvage, survival, primary patency, reintervention rate, adverse events, and partial and complete wound healing. Outcomes were evaluated using Kaplan-Meier method, log-rank, and two-stage procedure tests. ResultsTechnical success was achieved in 70 patients (96%) with 1 hospital (2.4%) and 2 OBL (6.3%) patients lost to follow-up. Major AFS estimates at 6 months, 1 year, and 2 years were 51.4%, 40.4%, and 30.2% in the hospital group and 69.4%, 54.0%, and 49.5% in the OBL group, respectively. Partial wound healing estimates at 6 months, 1 year, and 2 years were 27.5%, 71.7%, and 81.2% in the hospital group and 62.7% at all time points in the OBL group. Complete wound healing estimates at 6 months, 1 year, and 2 years were 6.7%, 33.3%, and 33.3% in the hospital group and 5.3%, 37.7%, and 41.6% in the OBL group, respectively. There was no significant difference in major AFS (P = .13), limb salvage (P = .07), survival (P = .69), primary patency (P = .53), partial (P = .08), or complete wound healing (P = .79) between groups. Reintervention was performed in 8 hospital (20.5%) and 14 OBL (45.2%) patients. ConclusionspDVA is a feasible and safe procedure for no-option critical limb ischemia in the hospital and OBL setting without significant differences in outcomes at ≤2 years.

Abstract 1143: Unraveling Histological Dynamics In Deep Venous Arterialization For Chronic Limb-threatening Ischemia

Introduction: Deep venous arterialization (DVA) is emerging as a promising alternative for no-option CLTI) but its pathophysiology remains incompletely understood. Research question: What histologic changes occur in the limb after DVA to allow tissue oxygenation? Study aim: To uncover histological alterations induced by DVA and provide a framework for future experimental models to explore early radiologic and histologic markers of successful DVA. Methods: We report the case of a 53-year-old female who underwent a percutaneous DVA for CLTI using a covered stent (Fig.1). The intervention was successful with evidence of improved blood flow to the foot, but the patient presented worsening infection leading to a below-knee amputation 4 weeks later. A high-resolution 7T MRI was used to scan the amputated limb, and the blood vessels were harvested for histology analysis. Results: The MRI confirmed the patency of the DVA stent graft (Fig. 2A) and plantar loop while histology demonstrated evidence of valvular disruption and eccentric neointimal hyperplasia (NIH) in the vein that underwent intervention (Fig 2B). There was also evidence of NIH and increased smooth muscle cells in the media of the paired vein that did not undergo intervention, resulting in greater thickness compared to the media of the anterior tibial vein at the same level (Fig 2C). Conclusion: Our case reveals some of the changes induced by DVA and demonstrates a possible role of the untouched paired vein in facilitating arterialized flow to the foot. This offers a framework for experimental studies to further investigate these histological alterations and their role in prognosticating DVA outcomes.

Deep Venous Arterialization – The Australian Experience

Deep Venous Arterialization – The Australian Experience

Open Venous Arterialization Technique for No-Option Foot Salvage: A Latino-American Cohort in a High-Volume CLTI Center

Open Venous Arterialization Technique for No-Option Foot Salvage: A Latino-American Cohort in a High-Volume CLTI Center

Magnetic Resonance Imaging and Histological Insights Into Deep Venous Arterialisation

Percutaneous deep venous arterialisation (DVA) is emerging as a promising alternative for limb salvage in chronic limb threatening ischaemia (CLTI) patients without any reasonable anatomical option for conventional revascularisation techniques. However, its mechanism of action remains incompletely understood. This report aimed to find some of the histological alterations occurring in the limb following DVA. This short report presents the case of a 53 year old female who underwent DVA for Rutherford 5 CLTI. Although the intervention was successful and showed evidence of improved blood flow to the foot, the post-operative course was notable due to worsening infection leading to a below knee amputation four weeks later. The blood vessels were harvested for histological analysis, which found features of venous arterialisation such as smooth muscle cell proliferation and neointimal hyperplasia, even in the paired posterior tibial vein that did not undergo DVA. This case demonstrated unexpected histological changes occurring in the paired posterior tibial vein that did not undergo DVA. This warrants further investigations to fully understand the mechanisms at play in DVA and to explore the role of the paired vein in sustaining arterialised flow to the foot.

Superficial venous arterialization with the great saphenous vein in situ: a single-center experience

Resumo Contexto A arterialização do arco venoso dorsal do pé é uma técnica indicada em casos de isquemia crítica de membros inferiores sem leito distal adequado que possibilite tratamento convencional, como revascularização, angioplastia ou tratamento clínico. Objetivos O propósito do trabalho foi apresentar o resultado da arterialização do arco venoso do pé em 16 pacientes submetidos a essa técnica. Métodos Tratou-se de um estudo analítico descritivo retrospectivo transversal, baseado na revisão de prontuários de 16 pacientes submetidos à arterialização do arco venoso dorsal do pé para salvamento de membro, entre janeiro de 2016 a janeiro de 2021. Resultados Dos 16 pacientes submetidos à arterialização do arco venoso do pé, 25% (4) evoluíram para amputação maior durante a mesma internação, e 6,25% (1) pacientes evoluíram para amputação maior após 6 meses. Os demais pacientes (68,75%, 11) tiveram seus membros preservados, sendo que 10 foram submetidos a amputações menores (pododáctilos e antepé), e 1 paciente não necessitou de procedimento adicional. Conclusões A técnica de arterialização do arco venoso dorsal do pé deve ser considerada em casos selecionados. Trata-se de uma alternativa válida para a preservação do membro na impossibilidade de tratamento convencional.

Superficial venous arterialization with the great saphenous vein in situ: a single-center experience.

Arterialization of the dorsal venous arch of the foot is a technique indicated in cases of critical lower limb ischemia that do not have a distal bed that is adequate to enable conventional treatment such as revascularization, angioplasty, or clinical treatment. The purpose of this study is to present the result of arterialization of the venous arch of the foot in 16 patients who underwent treatment with this technique. This is a cross-sectional retrospective descriptive analytical study based on a review of the medical records of 16 patients who underwent arterialization of the dorsal venous arch of the foot for limb salvage from January 2016 to January 2021. Four (25%) of the 16 patients who underwent arterialization of the venous arch of the foot underwent a major amputation during the same hospital stay and one patient (6.25%) had a major amputation within 6 months. The other 11 patients (68.75%) had their limbs preserved, with 10 undergoing minor amputations (toes and forefoot) and one patient having no additional procedures. We conclude that the technique of arterialization of the dorsal venous arch of the foot should be considered in selected cases. It is a valid alternative for limb salvage when conventional treatment is impossible.

Percutaneous Deep Venous Arterialization for Limb Salvage in No Option Patients with Chronic Limb-Threatening Ischemia.

An endovascular approach is often considered the first line treatment option for lower limb chronic limb-threatening ischemia (CLTI), which is defined by the presence of ischemic rest pain and severe tissue loss, such as ulcers or gangrene. Although the technical success rate of endovascular revascularization is high, in specific patients with advanced infrapopliteal disease and the absence of run-off tibial vessels, the so-called 'desert foot', the chance of successful endovascular revascularization is minimal. In order to avoid primary amputation, several treatment options are currently being investigated, including gene therapy and deep venous arterialization. This review focuses on the percutaneous deep venous arterialization technique as a promising, minimally invasive treatment option for limb salvage in CLTI patients presenting with a 'desert foot'.

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

PurposeTo 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 MethodsA 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. ResultsAll 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. ConclusionspDVA 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.

Percutaneous Deep Venous Arterialization for the Treatment of Buerger’s Disease

Purpose: Percutaneous deep venous arterialization (DVA) using a stent-graft system is a novel endovascular approach in the treatment of patients with Buerger’s Disease.

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.

The use of “off the shelf” percutaneous deep venous arterialization technology for a patient with severe chronic limb ischemia with no other options for limb salvage

The use of “off the shelf” percutaneous deep venous arterialization technology for a patient with severe chronic limb ischemia with no other options for limb salvage

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

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

Percutaneous deep venous arterialization with balloon angioplasty salvaged a life‐threatening critical limb in a hemodialysis patient after repeated pedal angioplasty failed: A case report

AbstractChronic limb‐threatening ischemia (CLTI) with severe below‐the‐ankle (BTA) lesions is often difficult to revascularize with endovascular treatment (EVT) and surgical treatment. We present a case of successful limb salvage using percutaneous deep venous arterialization (pDVA) in a patient with CLTI whose BTA lesion reconstruction failed. A 57‐year‐old man with diabetes mellitus and end‐stage renal failure on maintenance hemodialysis was referred to our hospital because of gangrene in the second and third toes of his left foot. EVT was repeated for the anterior tibial artery, posterior tibial artery (PTA), dorsal foot artery, and plantar artery lesions; however, revascularization below the ankle was unsuccessful. As the infection had spread to the sole of the foot, below‐the‐knee amputation was indicated, but the patient refused. Therefore, we performed pDVA on the left PTA simultaneously with a Lisfranc amputation. An arteriovenous fistula was created at the ankle joint using a Venous Arterialization Simplified Technique and a guidewire was inserted into the plantar vein. Balloon dilatation from PTA to the plantar vein was performed to complete the pDVA. Although repeated EVT was required to maintain blood flow in the pDVA, skin grafting was performed 3 months after the pDVA, the wound completely healed, and he was discharged 6 months after the DVA. The pDVA can be an option for limb salvage in patients with no‐option CLTI who are confronted by imminent amputation.

Fate mapping RNA-sequencing reveal Malat1 regulates Sca1+ progenitor cells to vascular smooth muscle cells transition in vascular remodeling

Regeneration of smooth muscle cells (SMCs) is vital in vascular remodeling. Sca1+ stem/progenitor cells (SPCs) can generate de novo smooth muscle cells after severe vascular injury during vessel repair and regeneration. However, the underlying mechanisms have not been conclusively determined. Here, we reported that lncRNA Metastasis-associated lung adenocarcinoma transcript 1 (Malat1) was down-regulated in various vascular diseases including arteriovenous fistula, artery injury and atherosclerosis. Using genetic lineage tracing mice and veingraft mice surgery model, we found that suppression of lncRNA Malat1 promoted Sca1+ cells to differentiate into SMCs in vivo, resulting in excess SMC accumulation in neointima and vessel stenosis. Genetic ablation of Sca1+ cells attenuated venous arterialization and impaired vascular structure normalization, and thus, resulting in less Malat1 down-regulation. Single cell sequencing further revealed a fibroblast-like phenotype of Sca1+ SPCs-derived SMCs. Protein array sequencing and in vitro assays revealed that SMC regeneration from Sca1+ SPCs was regulated by Malat1 through miR125a-5p/Stat3 signaling pathway. These findings delineate the critical role of Sca1+ SPCs in vascular remodeling and reveal that lncRNA Malat1 is a key regulator and might serve as a novel biomarker or potential therapeutic target for vascular diseases.