Single Center Outcomes Of Percutaneous Deep Vein Arterialization In Patients With End-stage Peripheral Artery Disease
Krystina N. Choinski, MD, Ajit G. Rao, MD, Nicholas J. Stafford, MD, Joshua D. Harris, MD, Windsor Ting, MD, Rami O. Tadros, MD, Ageliki G. Vouyouka, MD, Daniel K. Han, MD, Prakash Krishnan, MD, Peter L. Faries, MD.
Mount Sinai Hospital, New York, NY, USA.
Demographics:We describe a case series of 3 patients presenting with non-healing ulcers with end-stage peripheral artery disease (PAD) who underwent percutaneous deep vein arterialization (pDVA) between the posterior tibial (PT) artery and vein. Patient ages ranged from 56 to 81. Common comorbidities including diabetes, hypertension, hyperlipidemia, and former smoking.
History:Patients had multiple prior endovascular interventions, no open interventions, and two had prior toe amputations. All patients presented with non-healing distal ulceration of the affected extremity and no named blood vessels below the ankle on angiogram.
All patients underwent pDVA of the PT artery to PT vein (Table 1). Contralateral femoral artery access was utilized in two cases. One utilized antegrade, ipsilateral femoral access. The Outback Re-entry catheter (66%) and Pioneer Plus Re-entry catheter (33%) were used to cross from the PT artery to vein. This was subsequently treated with balloon angioplasty & covered stenting for fistula creation. Balloon angioplasty of tibial & pedal veins was performed for valve lysis & covered stenting of the PT vein occluded venous collaterals and minimized steal. Completion angiogram noted brisk filling of the venous pedal arch in all cases. Technical success was 100% in this cohort. There were no post-procedural complications. All patients were discharged on antiplatelet and anticoagulation therapy. All patients had initial resolution of rest pain post-procedure (Table 1). One patient underwent tarsometatarsal amputation (TMA) 2 weeks post DVA that remains well healed. One patient has continued resolution of rest pain and healed ulceration. One patient had progressive gangrene, which required a repeat angiogram, TMA, and ultimately below knee amputation. Overall, the freedom from major amputation in this cohort was 66%.
Progression of PAD can lead to end-stage disease in which there are no traditional distal targets for revascularization in the foot. These patients often have critical limb ischemia (CLI) and are referred to as “no option” CLI. pDVA attempts to provide blood flow to the preserved venous bed in the foot. Two patients healed successfully, one after TMA, and one required major amputation. Given their progressive disease, these patients will require close monitoring and coordinated wound care.
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