E5245. Can We Save the Foot? Percutaneous Deep Venous Arterialization for No-Option Critical Limb Ischemia 
  1. Neginder Saini; Holy Name Medical Center
  2. Laura Marrone; Holy Name Medical Center
  3. John Rundback; Holy Name Medical Center
Percutaneous deep venous arterialization is a minimally invasive technique used in patients with critical limb-threatening ischemia with nonreconstructible tibial and pedal arterial disease who are at imminent risk of amputation. The procedure involves creating a connection between a tibial artery and tibial vein to provide oxygenated blood to the foot through a retrograde fashion.

Educational Goals / Teaching Points
Explain the indications, risks, and benefits of percutaneous deep venous arterialization (pDVA). Explain the steps of the procedure as well as pre- and postoperative management. Discuss the various off-the-shelf devices being used for the procedure in addition to the proprietary system currently developed and being used in clinical trials. Review the literature on efficacy and outcomes following pDVA in patients with no-option critical limb-threatening ischemia. Provide early data on retrospective study currently underway at a single institution comparing outcomes at in-patient facility vs outpatient-based-laboratory.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Antegrade femoral artery access is obtained using ultrasound-guided micropuncture technique and recanalization of tibial arteries is performed as distal as possible. Venous access of the plantar or dorsalis pedis vein is obtained using ultrasound-guidance, and valvulotome is performed to allow for unobstructed retrograde flow. Depending on operator preference, different devices can be used to assist with arterial to venous puncture and fistula creation. Through and through access is obtained and balloon angioplasty of the arterial to venous anastomosis is performed followed by stent graft placement. Additional balloon angioplasty of the pedal venous arch is performed.

Percutaneous deep venous arterialization is a feasible option for patients with no-option critical limb-threatening ischemia with recent studies demonstrating promising results for amputation-free survival within a 1-year period. Further studies are required to evaluate for long-term outcomes.