Deep Vein Arterialization: A Comparison of Procedural Techniques

Learning Objectives:

1. 
   Describe the indications for Deep Vein Arterialization (DVA) in no-option chronic limb threatening ischemia (CLTI) patients
   
   


2. 
   Illustrate the three main percutaneous DVA (pDVA) creation approaches with case images, as well as describe the advantages and disadvantages of each
   
   


3. 
   Summarize patient selection with the existing options for DVA
   
   

Background: Peripheral artery disease affects an estimated 200 million people globally and has a myriad of medical and procedural therapies, but about 20% of patients with advanced disease are only left with major amputation as their only means of treatment {1}. These “no-option CLTI” patients face staggering rates of amputation and mortality, 30% and 50% at 1 year, respectively {2}. DVA is an innovative alternative for no-option CLTI patients, offering a revascularization strategy to prevent major amputations. This procedure involves arteriovenous fistula creation proximal to the diseased tibial artery, enabling retrograde delivery of oxygenated blood down to the pedal venous arch {1}. This exhibit will discuss the different pDVA techniques, highlighting the advantages and underscoring the limitations behind each method.

Clinical Findings/Procedure Details: Though there is no widely accepted classification of no-option CLTI, these patients typically have failed multiple attempts at revascularization, and are not suitable for endovascular or surgical recanalization. pDVA patients usually have Rutherford Class 5/6 CLTI with a preserved hindfoot/midfoot and no evidence of extensive gangrene or infection; they must have a viable foot for salvage attempts. This procedure is also relatively contraindicated in patients with severe heart failure or pulmonary hypertension, untreated chronic deep venous obstructive disease, acute DVT, life expectancy under 1 year, or no ambulatory potential.

pDVA has gone through varying changes in approach due to off the shelf, and now dedicated devices for its creation. Operator experience has evolved to adjust for predictable changes in the clinical outcomes in followup of these patients, such as edema, venous hypertension, venous steal, and other variables. The patient’s tibiopedal arterial and venous anatomy can vary, and detailed understanding of the limitations or benefits of each pDVA approach is important to consider for a successful procedure.

Conclusion and/or Teaching Points: A broader understanding of the pDVA methods will help vascular specialists tailor this procedure to the individual needs of patients and their varying anatomy, which is paramount to increase the chance of a successful outcome for limb preservation.