Clinical Pearls & Morning Reports
Published March 29, 2023
Relieving ischemia by arterializing the deep veins is not a new concept, having first been hypothesized and attempted more than 100 years ago and evaluated in multiple open surgical series. Shishehbor et al. conducted a prospective, single-group study that evaluated the effect of transcatheter arterialization of the deep veins on amputation-free survival and limb salvage as compared with an objective performance goal. Read the NEJM Original Article here.
Q: Who is a candidate for transcatheter arterialization of the deep veins?
A: Arterial revascularization is standard care for patients with chronic limb-threatening ischemia. Despite advances in surgical and endovascular treatment, up to 20% of patients with chronic limb-threatening ischemia are not candidates for revascularization (referred to here as no-option), primarily owing to the lack of an arterial target for distal runoff or an appropriate conduit for surgical bypass. Without the restoration of blood flow, no-option chronic limb-threatening ischemia that is characterized by pain, nonhealing wounds, and gangrene will progress to major (above-ankle) amputation in most cases. Major amputation for chronic limb-threatening ischemia is associated with 50% mortality within a year after amputation among patients over 65 years of age; mortality is higher among patients with coexisting cardiovascular conditions.
Q: How is transcatheter arterialization of the deep veins accomplished?
A: Transcatheter arterialization of the deep veins is an endovascular revascularization procedure for the treatment of no-option chronic limb-threatening ischemia. When the procedure is performed in the lower limbs, an arteriovenous fistula is created proximal to the diseased tibial arteries with the use of a covered stent. The oxygenated blood is then diverted from the tibial arteries to the tibial veins to bypass the severely diseased arterial vasculature. The venous system is leveraged to deliver oxygenated arterial blood to the foot through the pedal veins, which potentially averts major amputation and promotes wound healing.
A: In this prospective study involving patients with chronic limb-threatening ischemia and no conventional surgical or endovascular revascularization treatment options, transcatheter arterialization of the deep veins was successfully performed in 104 of 105 patients (99%), was associated with 66.1% amputation-free survival, and improved wound healing with complete healing in 16 patients (25.4%) and partial wound healing in 32 patients (50.8%) at 6 months.
A: Results of a prespecified subgroup analysis were aligned with those of previously published outcomes indicating an increased risk of death after peripheral arterial revascularization procedures among patients who were undergoing dialysis. Although the incidence of limb salvage was similar between patients who had dialysis-dependent chronic kidney disease and those who did not, mortality appeared to be greater in the population with dialysis-dependent disease. The decision to offer transcatheter arterialization of the deep veins to patients with dialysis-dependent chronic kidney disease should take into consideration life expectancy and patient preferences.