A Hemodynamic Scoring System for Optimizing Transcatheter Arterialization of the Deep Veins in No-Option Patients With Chronic Limb-Threatening Ischemia

Background Transcatheter arterialization of the deep veins (TADV) with LimFlow is an emerging revascularization strategy for patients with high-risk chronic limb-threatening ischemia (CLTI). Variability in outcomes highlights the need for structured tools to guide arteriovenous crossing-site selection and optimize perfusion. We propose an angiographic TADV scoring system to quantify the hemodynamic impact of donor artery selection and evaluate its association with clinical outcomes. Methods This retrospective analysis included 43 randomly selected patients from the PROMISE II trial with Rutherford class 5 to 6 no-option CLTI. Pre- and postprocedural angiograms were reviewed, and a TADV score (−4 to +4; lower scores indicating worse residual foot perfusion) was calculated by integrating below-the-knee arterial contribution with crossing-site selection. The primary outcome was change in ischemia-related pain. Secondary outcomes included limb salvage, amputation-free survival, wound healing, and secondary patency. Intraclass correlation coefficient assessed score reliability. Linear regression evaluated associations between TADV score and pain, and Cox regression assessed the relationship between pain and major amputation. Results Technical success was 100%. Mean pain decreased from 5.1 at baseline to 1.4 at 2 years, with median pain reaching 0 by 9 months. At 2 years, limb salvage was 60.7%, amputation-free survival 35.9%, and complete wound healing 62.5%. Intraclass correlation coefficient for the TADV score was 91.7%. Higher TADV scores were associated with lower pain at 1 and 3 months. Each one-point increase in pain increased major amputation risk (hazard ratio, 1.20; 95% CI, 1.02-1.41). Conclusions The TADV score correlates with early pain reduction and amputation risk, supporting its potential role in optimizing crossing-site selection and outcomes in no-option CLTI.