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Nakama T, Obunai K, Kojima S, Muraishi M, Watanabe H. Angiographic Findings of the Development of a Reverse Blood Supply After Percutaneous Deep Venous Arterialization. JACC Cardiovasc Interv 2020; 13:1489-1491. [PMID: 32222436 DOI: 10.1016/j.jcin.2020.01.225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 01/08/2020] [Accepted: 01/14/2020] [Indexed: 11/27/2022]
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52
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Ysa A. Commentary: Percutaneous Venous Arterialization: Should We Contain Our Enthusiasm? J Endovasc Ther 2020; 27:666-668. [PMID: 32425080 DOI: 10.1177/1526602820923059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- August Ysa
- Vascular Surgery Department, Hospital de Cruces, Barakaldo, Spain
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53
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Kim TI, Schneider PA. New Innovations and Devices in the Management of Chronic Limb-Threatening Ischemia. J Endovasc Ther 2020; 27:524-539. [PMID: 32419596 DOI: 10.1177/1526602820921555] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
As the number of patients afflicted by chronic limb-threatening ischemia (CLTI) continues to grow, new solutions are necessary to provide effective, durable treatment options that will lead to improved outcomes. The diagnosis of CLTI remains mostly clinical, and endovascular revascularization remains mostly balloon-based. Multiple innovative techniques and technologies are in development or in early usage that may provide new solutions. This review categorizes areas of advancement, highlights recent developments in the management of CLTI and looks forward to novel devices that are currently under investigation.
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Affiliation(s)
- Tanner I Kim
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California at San Francisco School of Medicine, San Francisco, CA, USA
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Schmidt A, Schreve MA, Huizing E, Del Giudice C, Branzan D, Ünlü Ç, Varcoe RL, Ferraresi R, Kum S. Midterm Outcomes of Percutaneous Deep Venous Arterialization With a Dedicated System for Patients With No-Option Chronic Limb-Threatening Ischemia: The ALPS Multicenter Study. J Endovasc Ther 2020; 27:658-665. [PMID: 32419597 DOI: 10.1177/1526602820922179] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Purpose: To evaluate the midterm results of patients suffering from no-option chronic limb-threatening ischemia (CLTI) treated with a dedicated system for percutaneous deep venous arterialization (pDVA). Materials and Methods: Thirty-two consecutive CLTI patients (mean age 67±14 years; 20 men) treated with pDVA using the Limflow device at 4 centers between 11 July 2014 and 11 June 2018 were retrospectively analyzed. Of all patients, 21 (66%) had diabetes, 8 (25%) were on immunosuppression, 4 (16%) had dialysis-dependent renal failure, 9 (28%) had Rutherford category 6 ischemia, and 25 (78%) were deemed at high risk of amputation. The primary outcome was amputation-free survival (AFS) at 6 months. Secondary outcomes were wound healing, limb salvage, and survival at 6, 12, and 24 months. Results: Technical success was achieved in 31 patients (96.9%). The median follow-up was 34 months (range 16-63). At 6, 12, and 24 months, estimates were 83.9%, 71.0%, and 67.2% for AFS, 86.8%, 79.8% and 79.8% for limb salvage, and 36.6%, 68.2%, and 72.7% for complete wound healing, respectively. Median time to complete wound healing was 4.9 months (range 0.5-15). The DVA circuit occluded during follow-up in 21 patients; the median time to occlusion was 2.6 months. Reintervention for occlusion was performed in 17 patients: 16 because of unhealed wounds and 1 for a newly developed ulcer. Conclusion: This study represents the largest population of patients with no-option CLTI treated with pDVA using the LimFlow device with midterm results. In this complex group of patients, pDVA using the LimFlow device has been shown to be feasible, with a high technical success rate and AFS at 6 up to 24 months coupled with wound healing. In selected patients with no-option CLTI, pDVA could be a recommended treatment to prevent amputation and heal wounds.
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Affiliation(s)
- Andrej Schmidt
- Department of Interventional Angiology, University Hospital Leipzig, Germany
| | | | - Eline Huizing
- Department of Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Costantino Del Giudice
- Department of Interventional Radiology, Hôpital Européen Georges Pompidou, Paris, France
| | - Daniela Branzan
- Department of Vascular Surgery, University Hospital Leipzig, Germany
| | - Çağdaş Ünlü
- Department of Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Ramon L Varcoe
- Department of Surgery, Prince of Wales Hospital and University of New South Wales, Randwick, Sydney, New South Wales, Australia
| | | | - Steven Kum
- Vascular Service, Department of Surgery, Changi General Hospital, Singapore
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Desai SS, Baronofsky H, Shukla N, Rahimi F. WITHDRAWN: One-Year Freedom from Amputation, Survival, and Cost of Care following Tibial and Pedal Endovascular Interventions for Critical Limb Ischemia: The Role of Atherectomy and Drug-Eluting Stents. Ann Vasc Surg 2020:S0890-5096(20)30269-7. [PMID: 32234574 DOI: 10.1016/j.avsg.2020.03.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/08/2020] [Accepted: 03/17/2020] [Indexed: 11/26/2022]
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal
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Affiliation(s)
- Sapan S Desai
- Northwest Community Healthcare, Arlington Heights, IL.
| | | | - Neal Shukla
- Northwest Community Healthcare, Arlington Heights, IL
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56
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Diagnostic and Therapeutic Approaches in the Management of Infrapopliteal Arterial Disease. Interv Cardiol Clin 2020; 9:207-220. [PMID: 32147121 DOI: 10.1016/j.iccl.2019.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Chronic limb-threatening ischemia represents end-stage peripheral artery disease. It is underdiagnosed; it relies on clinical symptoms and traditional noninvasive tests, which significantly underestimate the severity of disease. Innovative techniques, approaches, technologies, and risk-assessment tools have significantly improved our ability to treat these patients and to better understand their complex disease process. For patients with chronic limb-threatening ischemia considered without options, the reengineering of deep venous arterialization procedures has shown promising results. Finally, the creation of interactive and multidisciplinary teams in centers of excellence is of paramount importance to significantly improve the care and outcomes of these patients.
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Simplified Endovascular Deep Venous Arterialization for Non-option CLI Patients by Percutaneous Direct Needle Puncture of Tibial Artery and Vein Under Ultrasound Guidance (AV Spear Technique). Cardiovasc Intervent Radiol 2019; 43:339-343. [DOI: 10.1007/s00270-019-02388-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 11/25/2019] [Indexed: 12/19/2022]
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58
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Schreve MA, Lichtenberg M, Ünlü Ç, Branzan D, Schmidt A, van den Heuvel DAF, Blessing E, Brodmann M, Cabane V, Lin WTQ, Kum S. PROMISE international; a clinical post marketing trial investigating the percutaneous deep vein arterialization (LimFlow) in the treatment of no-option chronic limb ischemia patient. CVIR Endovasc 2019; 2:26. [PMID: 32026120 PMCID: PMC6966404 DOI: 10.1186/s42155-019-0067-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Critical limb ischemia (CLI) is the clinical end stage of peripheral artery disease and is associated with high amputation, mortality rates and poor quality of life. For CLI patients with no revascularization options, venous arterialization could be an alternative technique for limb salvage. A systematic review and meta-analysis published in 2017 concluded that venous arterialization may be considered a viable alternative. A recent development, is the Percutaneous Deep Vein Arterialization (pDVA), that is CE-marked and currently under investigation of the FDA. This procedure, called LimFlow, is a novel, minimally invasive, endovascular approach to perform a venous arterialization procedure. The limited evidence for its use necessitates a scientific judgement of the pDVA. Therefore, we initiated a prospective clinical post market trial to investigate the outcome of the pDVA in no-option critical limb ischemia. METHODS/DESIGN The objective of this prospective study is to collect "real-life" clinical data among a population of patients treated with the pDVA in order to evaluate the clinical effectiveness and safety of the LimFlow System in patients with no-option critical limb ischemia. This study is a single-arm, open-label, prospective, post-market follow-up study to be conducted on up to fifty (50) eligible patients with a twelve-month follow-up period. The Primary endpoint is measured by amputation free survival. Secondary endpoints are complete wound healing, primary and secondary patency, limb salvage, renal function and technical and procedural success. Patients will be assessed at regular intervals during one year after the initial percutaneous deep vein arterialization procedure through clinical evaluation and self-completed questionnaires. DISCUSSION The last decade several studies have been published with promising results and the number of treated patients has considerably grown. Venous arterialization could be a valuable treatment option in patients with often no other options than amputation of the affected limb. The first results in men are promising although more research and long term follow up is needed to establish the efficacy of this new treatment modality. With this prospective study, we evaluate the clinical effectiveness and safety in patients with no-option CLI treated with the pDVA (LimFlow System). TRIAL REGISTRATION NCT03321552 .
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Affiliation(s)
- Michiel A Schreve
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands, Wilhelminalaan 12, 1815 JD, Alkmaar, the Netherlands.
| | - Michael Lichtenberg
- Vascular Centre Arnsberg, Arnsberg Clinic, Arnsberg, Germany.,Standort Karolinen-Hospital, Stolte Ley 5, 59759, Arnsberg, Germany
| | - Çagdas Ünlü
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands, Wilhelminalaan 12, 1815 JD, Alkmaar, the Netherlands
| | - Daniela Branzan
- Department of Vascular Surgery, University Hospital Leipzig, Leipzig, Germany.,Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Germany
| | - Andrej Schmidt
- Department of Angiology, University Hospital Leipzig, Leipzig, Germany
| | - Daniel A F van den Heuvel
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands.,Ziekenhuis Nieuwegein, Koekoekslaan 1, 3435, CM, Nieuwegein, the Netherlands
| | - Erwin Blessing
- Department of Interventional Angiology, SRH Klinikum Karlsbad-Langensteinbach, Karlsbad, Germany.,SRH Klinikum Karlsbad-Langensteinbach GmbH, Guttmannstraße 1, 76307, Karlsbad, Germany
| | - Marianne Brodmann
- Angiologie, Medizinische Universtität Graz, Graz, Austria.,Medizinische Universtität Graz, Auenbruggerplatz 27, 8036, Graz, Austria
| | - Vincent Cabane
- LimFlow SA,Paris, France, 95 Boulevard Pereire, 75017, Paris, France
| | - William Tan Qing Lin
- Department of Surgery, Vascular Service, Changi General Hospital, Changi, Singapore.,Changi General Hospital Pte Ltd, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Steven Kum
- Department of Surgery, Vascular Service, Changi General Hospital, Changi, Singapore.,Changi General Hospital Pte Ltd, 2 Simei Street 3, Singapore, 529889, Singapore
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59
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Pua U, Huang IKH. Percutaneous Deep Vein Arterialization. J Vasc Interv Radiol 2019; 30:610-613. [PMID: 30910184 DOI: 10.1016/j.jvir.2018.07.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 07/25/2018] [Accepted: 07/26/2018] [Indexed: 10/27/2022] Open
Affiliation(s)
- Uei Pua
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ivan Kuang Hsin Huang
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433
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Ysa A, Lobato M, Mikelarena E, Arruabarrena A, Gómez R, Apodaka A, Metcalfe M, Fonseca JL. Homemade Device to Facilitate Percutaneous Venous Arterialization in Patients With No-Option Critical Limb Ischemia. J Endovasc Ther 2019; 26:213-218. [PMID: 30764701 DOI: 10.1177/1526602819830983] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To describe a maneuver to facilitate percutaneous arteriovenous fistula creation during venous arterialization procedures in patients with no-option critical limb ischemia. TECHNIQUE Following a failed arterial recanalization attempt, a balloon catheter is passed up to the tip of the guidewire. Venous access is gained distally, a 4-F sheath is antegradely passed, and a 4-mm GooseNeck snare is advanced through it. A fluoroscopic view that overlaps the snare and the inflated balloon is obtained. If the vein remains anterior with respect to the artery, a needle is inserted across the vein, passing through the snare loop and puncturing the intra-arterial balloon. A wire is inserted and placed inside the punctured balloon. The balloon is retrieved and the wire externalized through the femoral access. A catheter is advanced antegradely over this wire from the artery into the vein. If the vein remains posterior to the artery, a needle is inserted, puncturing the balloon and thereafter the vein (crossing through the snare). A wire is inserted, captured by the snare, and externalized through the vein sheath. A catheter is finally advanced over this wire from the vein into the artery. CONCLUSION This maneuver is a simple alternative to create an arteriovenous fistula during venous arterialization procedures in patients with no-option critical limb ischemia.
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Affiliation(s)
- August Ysa
- 1 Vascular Surgery Department, Hospital de Cruces, Barakaldo, Spain
| | - Marta Lobato
- 1 Vascular Surgery Department, Hospital de Cruces, Barakaldo, Spain
| | | | | | - Roberto Gómez
- 1 Vascular Surgery Department, Hospital de Cruces, Barakaldo, Spain
| | - Ana Apodaka
- 1 Vascular Surgery Department, Hospital de Cruces, Barakaldo, Spain
| | | | - Juan L Fonseca
- 1 Vascular Surgery Department, Hospital de Cruces, Barakaldo, Spain
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61
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Ferraresi R, Casini A, Losurdo F, Caminiti M, Ucci A, Longhi M, Schreve M, Lichtenberg M, Kum S, Clerici G. Hybrid Foot Vein Arterialization in No-Option Patients With Critical Limb Ischemia: A Preliminary Report. J Endovasc Ther 2018; 26:7-17. [PMID: 30591004 DOI: 10.1177/1526602818820792] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To describe a preliminary experience in treating no-option critical limb ischemia (CLI) patients with a hybrid foot vein arterialization (HFVA) technique combining open plus endovascular approaches. MATERIALS AND METHODS Between May 2016 and January 2018, 35 consecutive patients (mean age 68±12 years; 28 men) with 36 no-option CLI limbs underwent HFVA in our center. All limbs had grade 3 WIfI (Wound, Ischemia, and foot Infection) ischemia, and the wound classification was grade 1 in 4 (11%) limbs, grade 2 in 4 (11%), and grade 3 in 28 (78%). Surgical bypass was done on the medial marginal vein or a posterior tibial vein, followed by endovascular removal of foot vein valves and embolization of foot vein collaterals. A "tension-free" surgical approach was used to treat foot lesions. RESULTS At a mean follow-up of 10.8±2 months, limb salvage was achieved in 25 (69%) limbs and wound healing in 16 (44%); 9 patients presented an unhealed wound. Eleven (31%) patients underwent a major amputation (2 below the knee and 9 thigh). One patient with an unhealed wound and open bypass died of myocardial infarction. CONCLUSION HFVA is a promising technique able to achieve acceptable rates of limb salvage and wound healing in no-option patients generally considered candidates for an impending major amputation. Further studies are needed to standardize the technique and better identify patients who can benefit from this approach.
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Affiliation(s)
- Roberto Ferraresi
- 1 Peripheral Interventional Unit, Humanitas Gavazzeni, Bergamo, Italy
| | - Andrea Casini
- 2 Vascular Unit, Humanitas Gavazzeni, Bergamo, Italy
| | | | | | - Alessandro Ucci
- 4 Vascular Surgery, University of Parma, Maggiore Hospital, Parma, Italy
| | - Matteo Longhi
- 5 Vascular Surgery, University of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy
| | - Michiel Schreve
- 6 Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands
| | | | - Steven Kum
- 8 Vascular Service, Department of Surgery, Changi General Hospital, Singapore
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62
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Manzi M. Innovations in the management of the diabetic foot. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 59:653-654. [DOI: 10.23736/s0021-9509.18.10662-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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63
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Percutaneous Deep Venous Arterialization for Severe Critical Limb Ischemia in Patients With No Option of Revascularization: Early Experience From Two European Centers. Cardiovasc Intervent Radiol 2018; 41:1474-1480. [PMID: 30019194 DOI: 10.1007/s00270-018-2020-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To report our initial experience of fully percutaneous deep venous arterialization (pDVA) for the treatment of chronic critical limb ischemia (cCLI) after failed distal angioplasty. MATERIALS AND METHODS pDVA was performed in five consecutive patients by creating an arteriovenous fistula (AVF) between a below the knee artery and its satellite deep vein. In this early experience, only patients with failed prior interventional attempts at establishing flow with no distal targets for an arterial bypass were selected. Early technical success was defined as successful AVF creation and retrograde venous perfusion of the wound site. Patient demographics, procedural details, morbidity/mortality and wound healing outcomes were assessed prospectively. Patients were followed up in wound care centers, and graft patency was documented on duplex ultrasound. RESULTS All five consecutive patients (mean age 58 years) underwent successful pDVA without any procedural complications. There were neither 30-day major adverse limb events nor major cardiovascular complications. Three out of the five patients (60%) had clinical improvement as observed by resolution of rest pain and complete wound healing. At the 1-month FU, one patient died and one patient received a major amputation. The median wound healing time was 39 weeks. CONCLUSION pDVA is a safe and feasible vascularization alternative in patients with end-stage/no-option CLI. The early experience highlights the need for a multidisciplinary approach including a dedicated wound care service.
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Kum S, Huizing E, Schreve MA, Ünlü Ç, Ferraresi R, Samarakoon LB, van den Heuvel DA. Percutaneous deep venous arterialization in patients with critical limb ischemia. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 59:665-669. [PMID: 29786410 DOI: 10.23736/s0021-9509.18.10569-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Critical limb ischemia (CLI) is the presentation of end stage peripheral arterial disease and typically presents with rest pain, ulceration and gangrene. The outcome of conservative treatment is poor and often leads to amputations. Arterial revascularization plays an important role in amputation prevention. Unfortunately, a significant percentage of CLI patients cannot be revascularized and subsequently end up with a palliative amputation. This has led to the need and exploration of new treatment options in this no option subgroup of CLI. Deep venous arterialization (DVA) is one of them and has been reported as a save and feasible novel and promising alternative to amputation. The goal of DVA is to provide arterialized blood in significant volumes and pressure to the plantar venous arch and ischemic tissue to enable wound healing. Selecting the right patients is critical for successful DVA and requires that extra attention is paid to the wounds as well as arterial and venous vascular status. METHODS The procedure was previously described in our initial experience in the first-in-man study performed on 7 patients with NOP-CLI. The angiographic goal of the procedure is to deliver arterialized blood to the plantar venous arch in significant volumes and pressure, circumventing the numerous valves in the process. The clinical goal is to achieve wound healing. RESULTS Technical success was achieved in all patients. Flow in the plantar arch was achieved in 5 of the 7 patients. One patient with chronic rest pain became pain free within 48 hours after the procedure. Complete wound healing was achieved at 12 months in 5 of the 7 patients. Reinterventions were performed in 5 of 7 patients to maintain patency. Of the 7 study patients, five underwent minor amputation of one or more toes, and two underwent major amputations within 12 months (limb salvage, 71%). CONCLUSIONS The LimFlow system is currently the only registered device a total percutaneous DVA can be performed with. In addition to the percutaneous creation of an arteriovenous fistula (AVF), it also allows disruption of the veins with a dedicated valvulotome.
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Affiliation(s)
- Steven Kum
- Vascular Service, Department of Surgery, Changi General Hospital, Singapore, Singapore -
| | - Eline Huizing
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Michiel A Schreve
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Çagdas Ünlü
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Roberto Ferraresi
- Peripheral Interventional CathLab, Humanitas Gavazzeni, Bergamo, Italy
| | - Lasitha B Samarakoon
- Vascular Service, Department of Surgery, Changi General Hospital, Singapore, Singapore
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Gandini R, Merolla S, Scaggiante J, Meloni M, Giurato L, Uccioli L, Konda D. Endovascular Distal Plantar Vein Arterialization in Dialysis Patients With No-Option Critical Limb Ischemia and Posterior Tibial Artery Occlusion: A Technique for Limb Salvage in a Challenging Patient Subset. J Endovasc Ther 2017; 25:127-132. [DOI: 10.1177/1526602817750211] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To detail a percutaneous technique for distal plantar venous arterialization in diabetic, end-stage renal disease (ESRD) patients with no-option critical limb ischemia (CLI). Technique: After failure of standard intraluminal recanalization attempts, a subintimal approach through the posterior tibial artery (PTA) is begun using a 0.014-inch, 190- or 300-cm-long guidewire supported by a 2-×20-mm, low-profile balloon catheter positioned a short distance behind the narrow “U-shaped” loop in the guidewire. Typically, heavy calcification in the distal tortuous segment of the PTA prevents reentry to the arterial true lumen; however, an entry in the distal lateral or medial plantar vein from a subintimal channel in the plantar artery can be intentionally pursued as a bailout technique, pointing the tip of the guidewire opposite to the arterial wall calcifications. Venous access is confirmed by contrast injection through the balloon catheter. Once the guidewire is advanced in the distal lateral or medial plantar vein and a plantar arteriovenous fistula (AVF) has been created, the AV anastomosis and the occluded PTA segment are dilated with 0.014-inch balloon catheters. The technique has been attempted in 9 consecutive diabetic, ESRD patients (mean age 69 years; 5 men) with no-option CLI; an AVF was created between the PTA and plantar vein in 7 patients. The mean TcPO2 at 1 month was 30±17 mm Hg (vs 7.3±2.2 at baseline). Six ulcers healed over an average of 21±4 weeks. Three of the 9 patients had below-knee amputations. Conclusion: Although further investigations are required, distal plantar venous arterialization may represent a promising technique to improve recanalization rates and limb salvage in diabetic ESRD patients with extremely calcified PTA occlusions.
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Affiliation(s)
- Roberto Gandini
- Department of Diagnostic and Molecular Imaging, Interventional Radiology, and Radiation Therapy, University of Tor Vergata, Rome, Italy
| | - Stefano Merolla
- Department of Diagnostic and Molecular Imaging, Interventional Radiology, and Radiation Therapy, University of Tor Vergata, Rome, Italy
| | - Jacopo Scaggiante
- Department of Diagnostic and Molecular Imaging, Interventional Radiology, and Radiation Therapy, University of Tor Vergata, Rome, Italy
| | - Marco Meloni
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Laura Giurato
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Luigi Uccioli
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Daniel Konda
- Department of Diagnostic and Molecular Imaging, Interventional Radiology, and Radiation Therapy, University of Tor Vergata, Rome, Italy
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Stem Cell Therapies in Peripheral Vascular Diseases — Current Status. JOURNAL OF INTERDISCIPLINARY MEDICINE 2017. [DOI: 10.1515/jim-2017-0093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Abstract
Peripheral artery diseases include all arterial diseases with the exception of coronary and aortic involvement, more specifically diseases of the extracranial carotids, upper limb arteries, mesenteric and renal vessels, and last but not least, lower limb arteries. Mononuclear stem cells, harvested from various sites (bone marrow, peripheral blood, mesenchymal cells, adipose-derived stem cells) have been studied as a treatment option for alleviating symptoms in peripheral artery disease, as potential stimulators for therapeutic angiogenesis, thus improving vascularization of the ischemic tissue. The aim of this manuscript was to review current medical literature on a novel treatment method — cell therapy, in patients with various peripheral vascular diseases, including carotid, renal, mesenteric artery disease, thromboangiitis obliterans, as well as upper and lower limb artery disease.
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Lichtenberg M, Schreve MA, Ferraresi R, van den Heuvel DAF, Ünlü Ç, Cabane V, Kum S. Surgical and endovascular venous arterialization for treatment of critical limb ischaemia. VASA 2017; 47:17-22. [PMID: 29065790 DOI: 10.1024/0301-1526/a000669] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Patients with critical limb ischaemia have a poor life expectancy. Aggressive revascularization is accepted in order to preserve their independence in the final phase of their lives. Bypass surgery and more recently endovascular interventions with angioplasty and stenting have become the treatment of choice to prevent amputation and to resolve pain. However, as many as 20 % of patients with critical limb ischaemia are unsuitable candidates for a vascular intervention because of extensive occlusions of outflow in the crural and pedal vessels. Such "no-option critical limb ischaemia" may be treated with venous arterialization. In the present review, we discuss the history of the venous arterialization procedure, the mechanisms, the different techniques, and complications of venous arterialization.
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Affiliation(s)
| | - Michiel A Schreve
- 2 Department of Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Roberto Ferraresi
- 3 Peripheral Interventional Unit, Humanitas Gavazzeni, Bergamo, Italy
| | | | - Çagdas Ünlü
- 2 Department of Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Vincent Cabane
- 5 Vascular Service, Department of Surgery, Changi General Hospital, Changi, Singapore
| | - Steven Kum
- 5 Vascular Service, Department of Surgery, Changi General Hospital, Changi, Singapore
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Mills JL. Commentary: Is Deep Vein Arterialization for Limb-Threatening Ischemia Effective? A Novel Percutaneous Technique May Lead to an Answer. J Endovasc Ther 2017; 24:627-628. [PMID: 28830275 DOI: 10.1177/1526602817728045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Joseph L Mills
- 1 Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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