Marta Lobato & August Ysa

72yo male, NKA, former heavy smoker. Atrial fibrillation, COPD, CKD. Under long-term corticosteroid therapy.

The patient was admitted with a necrotic ulcer on the 2^nd toe of the right foot (W2I3FI1). He had undergone a prior BTK recanalization attempt (PTA and peroneal artery angioplasty) without any success on reaching the BTA vessels. MAC score 5.

On physical examination: No pulses below the knee bilaterally. ABI non compressible. TCPO2 21mmHg.

It was considered a no-option patient and therefore we decided to perform a hybrid DVA on the superficial dorsal system.

Since the GSV below the knee had an inadequate caliber, we performed a variation of Lengua´s technique using the GSV of the thigh. The proximal anastomosis of the bypass was on the P3 segment (side to end) and the distal one on the distal GSV (4cm above the ankle (end to end)).

Finally the medial marginal vein was dilated with a 4mm balloon in order to destroy the venous valves. Following R. Ferraresi´s theory (scape from the fortress), we also drained the MMV on the first toe main vein (3mm balloon angioplasty).

Up to 20% of patients with Critical Limb Ischemia (CLI) are not considered good candidates for endovascular revascularization. If recanalization of a chronic occlusion of a BTK/ BTA artery proves to be impossible owing to the inability to cross an extensive occlusion or in the presence of a “desert foot”, percutaneous venous arterialization has proven to be a bailout strategy for limb salvage. Drs. August Ysa and Marta Lobato, from Vascular Surgery Dpt. Hospital de Cruces, Barakaldo (Spain), present the last update in Percutaneous Venous Arterialization technique and expose a Case in the box.

After an unsuccessful antegrade recanalization attempt of the ATA/DP  due to vessel perforation, an extreme retrograde puncture of the first metatarsal artery was performed. Following a  1.5 mm balloon dilatation, the rendezvous of the wires was obtained using the CART technique. 2 mm DCB balloon angioplasty of the DP, 2.5mm for the distal ATA and 3mm for the proximal ATA were subsequently performed.  The completion angio showed full blushing of the target lesion, and  excellent flow on the forefoot including the plantar arch.

Although we favor a more distal location of the AVF to circumvent the need to use covered stent extensions to destroy the valves and avoid bleeding off venous flow via collaterals, sometimes (e.g. due to extreme vessel calcification) it is unavoidable to have to look for a more proximal inflow. The versatility of the VAST maneuver allows to perform a proximal DVA at the origin of the PT artery with conventional off-the-shelf devices.”

JEVT 2019 Apr;26(2):213-218
JEVT 2019 Jun;26(3):427-428