Deep Venous Arterialization – The Australian Experience

Chronic limb threatening ischemia (CLTI) represents the end-stage of peripheral arterial disease (PAD). It is characterized by ischemic rest pain and tissue loss. It causes significant morbidity, with over 20% of affected patients having major limb amputations, which itself has public health implications. Treatment of CLTI is nuanced, with the development of complex revascularisation techniques. However, there's a subset of patients that have no distal arterial targets for reconstruction, or severe infra-malleolar disease that cannot be revascularized. This group of patients have 'no-option CLTI', in whom deep venous arterialization (DVA) could be considered as an option for limb salvage. DVA is a reconstructive technique in which an arteriovenous fistula is created between a proximal non-diseased lower limb artery and deep vein, arterializing the vein and venous beds of the foot, theoretically revascularizing the foot. It is a novel technique performed with either endovascular or open approaches, with international series reporting 12-month limb-salvage rates of 70%. We discuss our experience of DVA over the past two years in an Australian, regional tertiary center. Patients who have had DVA were identified by reviewing operation lists between January 1, 2021 and February 1, 2023. Data were collected from electronic medical records, including demographics data, comorbidities, details of the operations (indication, proximal and distal bypass targets, conduit, valvulotomy, proximal ligation), 30-day mortality, major limb amputation, graft patency and wound healing. DVA revascularized 5 limbs in 4 patients. All operations were performed for CLTI with tissue loss, with unreconstructible infragenicular arterial disease. All cases anastomosed the below-knee popliteal artery with the posterior tibial vein, using reversed great saphenous vein conduit. All cases valvotomized and proximally ligated the target vein. There was no operative mortality. Twelve-month limb salvage-rate was 80%, with 1 limb (20%) requiring a major amputation 3 months post-DVA; 80% of limbs achieved complete wound healing; and 1 limb (20%) required further endovascular intervention. Out of the 4 limbs that were salvaged, 75% of grafts were patent at 12 months follow-up. In our experience, we can conclude that DVA for 'no-option CLTI' is a safe procedure that achieves reasonable limb-salvage rates in patients who would otherwise require major amputations.