Duplex and Angiographic-Assisted Evaluation of Outcomes of Endovascular Embolization after Surgical Deep Vein Arterialization for the Treatment No-Option Critical Limb Ischemia Patients

Abstract

Objective: To report early and mid-term outcomes of the arterialization of the deep venous system in no-option critical limb-threatening ischemia (CLTI) using duplex ultrasound and angiographic evaluation to improve limb perfusion.

Methods: A single-center prospective study of patients with no-option CLTI treated with hybrid surgical arterialization of the deep venous circulation and staged endovascular embolization of the venous collateral. Embolization was performed using a controlled-release spiral, within two weeks after bypass surgery. Patients were assessed for clinical status, wound healing, median transcutaneous partial pressure of O₂ (TcPO₂), and post-operative duplex ultrasound evaluating peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) to assess foot perfusion and bypass features. Primary endpoint analysis was primary technical success, limb salvage, patency rates, and clinical improvement. Secondary endpoints were 30-day and long-term mortality, major cardiovascular events (MACE), including myocardial infarction or stroke, and serious adverse events (SAE).

Results: Five patients with no-option CLTI were treated at our center using the hybrid deep vein arterialization technique. Clinical stage was grade 3 in one patient and grade 4 in the remaining four. Mean age was 65.8 years (range 49-76 years), and two patients were affected by Buerger's disease. Primary technical success was achieved in all patients, and all the bypasses were patent at the angiographic examination. At 30-day and at average follow-up of 9.8 months (range 2-24 months), mortality, major cardiovascular events (MACE), and serious adverse events (SAE) were not reported, with a primary patency and limb salvage rates of 100%. Three patients required minor amputation. Clinical improvement was demonstrated in all patients with granulation, resolution of rest pain, or both. Median TcPO₂ values rose from 10 mm Hg (range 4-25) before the procedure to 35 (range 31-57) after surgery, and to 59 mm Hg (range 50-76) after the staged endovascular procedure.

Conclusions: In our initial experience, the arterialization of the deep venous circulation, with subsequent selective embolization of the venous escape routes from the foot, seems a feasible and effective solution for limb salvage in patients with no-option CLTI and those in the advanced wound, ischemia, and foot infection (WIfI) clinical stage.

Keywords: chronic limb-threatening ischemia; critical limb ischemia; deep vein arterialization; no-option chronic limb-threatening ischemia.

Figure 1

(A) Pre-operative computed tomography angiography showing posterior view of right limb distal SFA, with popliteal and infrapopliteal tibial vessels occlusion without patent vessels crossing the ankle in the patient with Rutherford 4 and CS 4; (B) baseline angiography in patient with advanced forefoot gangrene, exhibiting distal posterior tibial occlusion, partial recanalization of distal anterior tibial, and peroneal arteries without target artery crossing ankle into foot; P2 patterns according to inframalleolar/pedal disease descriptor in the Global Limb Anatomic Staging System (GLASS).

Figure 2

(A) Intraoperative details showing the distal anastomosis performed at the level of the perimalleolar tibial vein in a termino-lateral fashion; (B,C) angiographic examination, performed 10 days after first surgery, revealing bypass patency and the main venous collateral, causing rapid wash-out of the contrast medium towards the leg, downstream of the distal anastomosis (white arrow); (D,E) selective catheterization of the collateral and embolization by a controlled-release spiral; (F,G) final angiography showing the occlusion of the main venous collateral and the implemented distal perfusion of the foot.

Figure 3

(A,B) Extensive forefoot gangrene; (C) open trans-metatarsal amputation performed after arterialization, avoiding primary closure according to the “tension-free” surgical approach; (D) complete healing of the amputation wound after VAC therapy.

Figure 4

Post-operative duplex ultrasound examination showing bypass flow (A) and distal foot arteries perfusion (B) after surgical revascularization, and at the same levels after the embolization procedure (C,D).