How to Give An Option to No-Option Critical Limb Ischemia

Monday, March 31, 2025

5:10 PM – 5:15 PM CT

Location: Music City Center, 205 BC

Abstract Presenter(s)

Karan B. Singh, MD (he/him/his)

Integrated Vascular & Interventional Radiology Resident
SSM Health Saint Louis University, United States

Author/Co-author(s)

RN

Ravneet Nagra, MPH, MS

MS3
Saint Louis University School of Medicine, United States
JM

Jesse Martin, MD

Chief Fellow, Division of Vascular & Interventional Radiology
SSM Health Saint Louis University, United States
DK

Deepak Kesani, DO

VIR Indepedent fellow
Saint Louis University School of Medicine, United States
NM

Nicolas Maynard, MD

Integrated Vascular & Interventional Radiology Resident
St. Louis University, Department of Radiology, IR, United States
Millie Liao, DO, MS

attending and faculty
Saint Louis University School of Medicine, United States
AM

Aliabdullah Malik, MD

Vascular & Interventional Radiology Faculty
Saint Louis University Hospital, United States
DO

David Owens, DO

Vascular & Interventional Radiology Faculty and Associate Program Director for the Diagnostic Radiology Residency
Saint Louis University, United States
Keith Pereira, MD, DABR, RPVI, ABWM, FSIR

Associate Professor -Tenured
Saint Louis University School of Medicine, United States

Learning Objectives:

Review indications of percutaneous deep venous arterialization in critical limb ischemia.

Describe the procedural details (with pictures) of percutaneous deep venous arterialization.

Background:

Critical limb ischemia (CLI) is the most advanced form of peripheral arterial disease and has a 50% mortality rate at 5 years. Traditional intervention is surgical or endovascular revascularization and is not a viable option in 10-40% of these patients, who instead undergo limb amputation {1}. The mortality rate of patients requiring above-the-knee amputation is 50%, and of the patients who survive past 24 months, only 40% are ambulatory {2}. Percutaneous deep venous materialization (pDVA) is a novel technique in which the venous system is leveraged to deliver oxygenated blood to ischemic tissue: an arteriovenous fistula is created between the distal tibial vein and artery and is particularly beneficial for patients with small artery disease (SAD). Severe calcifications are present in a majority of patients with SAD and have insufficient blood flow to distal tissue, limiting available arterial targets for traditional revascularization. Patients with CLI Rutherford class 4-6 who underwent pDVA were shown to have limb salvage rates as high as 55-80% in 24 months, immediate pain relief, and median wound healing rates of 6 months {3-7}. 

Clinical Findings/Procedure Details: This educational exhibit will provide step-by-step procedural instructions, along with pictures, to highlight the creation of an AV fistula in the distal extremities for pDVA. This includes plantar vein access, femoral access, gunsight and flossing, and venovalvotomy techniques. We also describe the selection of balloons and high-pressure angioplasty and venoplasty. Further, given the significance of ensuring reverse flow in the deep plantar venous arch, this exhibit describes the placements of stents, intraprocedural imaging, and post-procedural follow-up.

Conclusion and/or Teaching Points: pDVA is an effective option for patients with CLI with significant small vessel disease that can reduce rates of above-the-knee amputation and improve wound healing.  Interventional radiology can use advances in the pDVA technique to treat patients with otherwise irrecoverable limbs and consequently, improve limb salvage rates and patient outcomes.