Deep Venous Arterialization In Conjunction With Prosthetic Distal Bypass For Limb Preservation
Richard Neville, MD, Michael Parker, MD, Joseph Babrowicz, MD, Anthony Comerota, MD.
Inova Health System, Falls Church, VA, USA.
Objectives: A number of patients present with the “desert foot” phenomenon manifest by limited options for arterial revascularization. This report describes early results of a technique combining prosthetic bypass with deep venous arterialization (DVA) to establish perfusion in those patients with severely disadvantaged arterial runoff.
Methods: Over twelve months, four bypasses were performed with prosthetic conduit and concomitant DVA. All patients (2 male, 2 female) were facing major amputation due to a lack of a distal arterial target. All patients presented with CLTI manifest as severe rest pain (2) and tissue loss (2); three with diabetes mellitus, one on dialysis. Three patients had undergone prior attempts at endovascular revascularization. At surgery, a tibial bypass was performed using a heparin bonded ePTFE conduit with a distal vein patch anastomosis (DVP). A common ostium AVF was created between the tibial artery and corresponding tibial vein with a valvulotome introduced per the fistulous connection into the tibial vein to disrupt the valves in the vein beyond the ankle level. Completion ultrasound demonstrated flow into the venous outflow tract with variable flow into the corresponding artery. Follow-up ranged from 1-6 months with graft function evaluated by exam and Duplex ultrasound surveillance.
Results: The proximal anastomosis originated from the CFA (3) or SFA (1) with the outflow vascular pedicle based on the posterior tibial (3) and anterior tibial (1) arteries. Patients were anticoagulated on heparin for 48 hours and discharged on dual antiplatelet therapy (aspirin and clopidogrel) with one patient on aspirin and apixaban due to clopidogrel resistance. At follow-up, all grafts remained patent by pulse exam and ultrasound images, with resolution of rest pain (2) and complete healing (2). Venous hypertension was not problematic in any limb. Average ABI increased (0.26 to 0.97) as did TBI (0.07 to 0.57).
Conclusion: This early experience describes DVA using a prosthetic conduit in conjunction with the DVP technique in patients with threatened limb loss and severely disadvantaged tibial runoff. Although evidence for long-term efficacy is uncertain, the addition of DVA may be of benefit in the patient with CLTI considered non-reconstructible by current modalities. Further investigation is warranted as this technique may allow for DVA by surgical bypass resulting in limb preservation for patients with no other alternative than amputation.
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