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Tsukagoshi J, Orrukem M, Shimamura J, Secemsky EA, Nakama T, Yokoyama Y, Takagi H, Kuno T. Short and Midterm Outcomes of Percutaneous Deep Venous Arterialisation for No Option Chronic Limb Threatening Ischaemia: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00657-9. [PMID: 39121906 DOI: 10.1016/j.ejvs.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 06/24/2024] [Accepted: 08/01/2024] [Indexed: 08/12/2024]
Abstract
OBJECTIVE Percutaneous deep venous arterialisation (pDVA) is a state of the art technique for treating patients with chronic limb threatening ischaemia (CLTI) with no conventional option for revascularisation. There are limited large scale data examining the clinical effectiveness of pDVA for patients with end stage CLTI. DATA SOURCES MEDLINE, Embase, Google Scholar, and Cochrane databases. REVIEW METHODS Four databases were searched from January 2018 to June 2024 to identify studies investigating the feasibility and clinical outcomes of pDVA for patients with CLTI with no conventional revascularisation options. Meta-analysis of time to event outcomes (mean ± standard deviation) was performed for amputation free survival as the primary outcome, and freedom from amputation and overall survival as secondary outcomes. Other secondary outcomes (mean and 95% confidence interval [CI]) were procedural success rate, patency, re-intervention, and complete wound healing. RESULTS Ten non-randomised studies were included with 351 patients. The mean patient age was 70.3 years, and 67.6% were male. Most procedures used the posterior tibial artery. The aggregated rate of amputation free survival at six and twelve months (five studies, 260 patients) was 72.6 ± 2.8% and 66.0 ± 3.1%, respectively, while the overall survival at six and twelve months (five studies, 260 patients) was 85.0 ± 2.3% and 77.7 ± 2.9%, respectively. The procedural success rate (nine studies, 330 patients) was 95.5% (95% CI 92.4 - 98.7%). Primary and secondary patency at six months (four studies, 241 patients) was 23.4% (95% CI 13.6 - 33.2%) and 54.9% (95% CI 34.3 - 75.5%), respectively. The rates of re-intervention (four studies, 190 patients) and complete wound healing (five studies, 190 patients) at twelve months were 41.7% (95% CI 25.7 - 57.7%) and 46.0% (95% CI 31.7 - 60.3%), respectively. CONCLUSION This meta-analysis demonstrated acceptable feasibility for no option CLTI at highly specialised institutions for patients undergoing pDVA. Meta-analysis of time to event outcomes revealed that pDVA provides reasonable amputation free survival for up to twelve months, albeit with a overall low certainty of evidence. Wider adoption of pDVA may be considered in selected patients with CLTI, although its clinical impact and cost effectiveness require further evaluation.
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Affiliation(s)
- Junji Tsukagoshi
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA. https://twitter.com/tj_TeamWADA
| | - Martin Orrukem
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Junichi Shimamura
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Centre, Valhalla, NY, USA. https://twitter.com/ShimamuraMD
| | - Eric A Secemsky
- Division of Cardiology, Beth Israel Deaconess Medical Centre, Boston, MA, USA. https://twitter.com/EricSecemskyMD
| | - Tatsuya Nakama
- Department of Cardiology, Tokyo Bay Medical Centre, Urayasu, Japan. https://twitter.com/tatsuya_nakama
| | - Yujiro Yokoyama
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA. https://twitter.com/YujiroYokoyamaD
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Centre, Shizuoka, Japan
| | - Toshiki Kuno
- Department of Cardiology, Montefiore Medical Centre, Albert Einstein College of Medicine, New York, NY, USA; Department of Cardiology, Jacobi Medical Centre, Albert Einstein College of Medicine, New York, NY, USA; Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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So SE, Chan YC, Cheng SW. Efficacy and Durability of Percutaneous Deep Vein Arterialization: A Systematic Review. Ann Vasc Surg 2024; 105:89-98. [PMID: 38579910 DOI: 10.1016/j.avsg.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 12/07/2023] [Accepted: 01/06/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Endovascular deep vein arteriaization (DVA) is a novel technique aimed at salvaging peripheral arterial disease unamenable to conventional surgical intervention. This study aims to review contemporary literature on the efficacy, safety, and durability of DVA on patients with no-option critical limb ischemia (NO-CLI). METHODS The study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, using predefined search terms of "percutaneous deep vein arterialization" or "percutaneous deep venous arterialization" in PubMed, Web of Sciences, OvidSP, and Embase. Only studies with 5 or more patients were included, and studies involving open or hybrid DVA were excluded. The primary outcomes included technical success and primary amputation rates. Secondary outcomes included rates of wound healing, complication, reintervention, and all-cause mortality. RESULTS Ten studies encompassing a total of 233 patients were included. Patients were primarily those deemed to have NO-CLI. The median follow-up period was 12 months (range 1-63 months). The technical success rate was 97% (95% confidence interval [CI] 96.2%-97.9%) and the major amputation rate was 21.8% (95% 21.1%-22.4%). The wound healing rate was 69.5% (95% CI 67.9-71.0%), complication rate was 13.8% (95% CI 11.7%-15.9%), reintervention rate was 37.4% (95% CI 34.9%-39.9%), and all-cause mortality rate was 15.7% (95% CI 14.1%-17.2%). CONCLUSIONS Our study showed that endovascular DVA is safe for patients with NO-CLI. Nonetheless, studies were small with follow-up period of less than 1 year. There is currently lack of level 1 evidence to recommend routine use in patients with NO-CLI.
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Affiliation(s)
- Samuel E So
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong SAR, China
| | - Yiu Che Chan
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong SAR, China.
| | - Stephen W Cheng
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong SAR, China
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Lepow BD, Zulbaran-Rojas A, Park C, Chowdhary S, Najafi B, Chung J, Ross JA, Mills JL, Montero-Baker M. Guillotine Transmetatarsal Amputations With Staged Closure Promote Early Ambulation and Limb Salvage in Patients With Advanced Chronic Limb-Threatening Ischemia. J Endovasc Ther 2024; 31:687-696. [PMID: 36565249 DOI: 10.1177/15266028221144587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE Transmetatarsal amputation (TMA) with primary closure has long been an option for limb salvage in patients with advanced chronic limb-threatening ischemia (CLTI) with extensive tissue loss of the forefoot. However, TMA healing and closure techniques are challenging, specifically in high-risk patients. Guillotine transmetatarsal amputations (gTMA) with staged closure may provide an alternative treatment in this population. We report long-term outcomes of such technique. MATERIALS AND METHODS A single-center retrospective cohort study of CLTI patients undergoing gTMA between 2017 and 2020 was performed. Limb salvage, wound healing, and survival rates were quantified using Kaplan-Meier (KM) analysis. Multivariate regression was used to identify the effect of patient characteristics on the outcomes. RESULTS Forty-four gTMA procedures were reviewed. Median follow-up was 381 (interquartile range [IQR], 212-539.75) days. After gTMA, 87.8% (n=36) of the patients were able to ambulate after a median interval of 2 (IQR, 1-3) days. Eventual coverage was achieved in a personalized and staged approach by using a combination of skin substitutes (88.6%, n=39) ± split thickness skin grafts (STSG, 61.4%, n=27). KM estimates for limb salvage, wound healing, and survival were 84.1%, 54.5%, and 88.6% at 1 year and 81.8%, 63.8%, and 84.1% at 2 years. Wound healing was significantly associated with STSG application (p=0.002, OR=16.5, 95% CI 2.87-94.81). CONCLUSION gTMA resulted in high limb salvage rates during long-term follow-up in CLTI patients. Adjunctive STSG placement may enhance wound healing at the gTMA site, thus leading to expedited wound closure. Surgeons may consider gTMA as an alternative to reduce limb loss in CLTI patients at high risk of major amputation. CLINICAL IMPACT Currently, the clinical presentation of CLTI is becoming more complex to deal with due to the increasing comorbidities as the society becomes older. The data shown in this article means for clinicians that when facing diffused forefoot gangrene and extensive tissue loss, limb preservation could still be considered instead of major amputation. Guillotine transmetatarsal amputations in the setting of an aggressive multidisciplinary group, can be healed by the responsibly utilization of dermal substitutes and skin grafts leading to the preservation of the extremity, allowing mobility, avoiding of sarcopenia, and decreasing frailty. This will equate to maintenance of independent living and preservation of lifespan.
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Affiliation(s)
- Brian D Lepow
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Alejandro Zulbaran-Rojas
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Catherine Park
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Michael E. DeBakey VA Medical Center, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, VA Health Services Research & Development, Houston, TX, USA
- The Big Data Scientist Training Enhancement Program, VA Office of Research & Development, Washington, DC, USA
| | - Saakshi Chowdhary
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Bijan Najafi
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Jayer Chung
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Jeffrey A Ross
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Miguel Montero-Baker
- Vascular Surgery, Houston Methodist Cardiovascular Surgery Associates, Houston, TX, USA
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Choinski KN, Rao AG, Krishnan P, Tadros RO, Sharma R, Faries PL. Single Center Outcomes of Percutaneous Deep Vein Arterialization in Patients with End-Stage Peripheral Artery Disease. Vasc Endovascular Surg 2024; 58:548-553. [PMID: 38164900 DOI: 10.1177/15385744231226047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Background: Peripheral artery disease (PAD) can present as chronic limb threatening ischemia (CLTI) with ischemic pain and tissue loss. Progression of distal disease can lead to a "no option" or end-stage disease without traditional open or endovascular revascularization due to lack of pedal targets. Innovations in endovascular technology allow for the use of percutaneous deep vein arterialization (pDVA) to treat patients with CLTI. Purpose: We describe our experience and technique for treating four patients with end-stage PAD with pDVA. Research Design: Four patients with end-stage PAD were followed during and after pDVA creation. Technical success, complications, wound healing, and freedom from major amputation were analyzed. Data Collection and Analysis: Patient data and outcomes were collected via chart review and at time of follow up appointments in vascular surgery clinic. Results: Technical success was 100%, without post-procedural complications, and patients were continued on antiplatelet and anticoagulation. Three patients (75%) had successful wound healing, with 2 patients healing after transmetatarsal amputation (TMA), and 1 healing a distal foot ulceration that did not require surgery. One patient had worsening ischemic breakdown of a TMA, despite re-intervention on the pDVA, which required a below knee amputation (BKA). Freedom from major amputation was 75% overall, with an average follow-up time of 410 days post-procedure (Range: 113-563 days). Conclusions: Percutaneous deep vein arterialization attempts to provide blood flow to the preserved venous bed in patients with end-stage PAD. Exploration and utilization of this technique continues to expand in the modern vascular era. This case series highlights 4 patients with end-stage PVD who underwent pDVA, with 100% procedural success, and 75% limb salvage rate.
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Affiliation(s)
- Krystina N Choinski
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ajit G Rao
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Prakash Krishnan
- The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rami O Tadros
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Raman Sharma
- The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter L Faries
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Srinivasan A, Miranda J, Mills JL. Appropriate care in chronic limb threatening ischemia: A review of current evidence and outcomes. Semin Vasc Surg 2024; 37:249-257. [PMID: 39152003 DOI: 10.1053/j.semvascsurg.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/27/2024] [Accepted: 04/04/2024] [Indexed: 08/19/2024]
Abstract
Chronic limb threatening ischemia (CLTI) poses a significant treatment challenge for vascular surgeons, interventionalists, podiatrists, and associated medical specialists. The evidence for what constitutes appropriate care is rapidly evolving and new treatment options are in constant development. This review examines the current guidelines for CLTI care, as well as reported outcomes for multiple care strategies in this patient population, including revascularization and medical optimization. We performed a literature review of the PubMed database, reviewing articles that reported outcomes for CLTI care between 2000 and 2023, and described these outcomes as they relate to the current state of CLTI treatment. Significant data are still forthcoming regarding CLTI care, but widespread adoption of appropriate CLTI care is essential for the treatment of this vulnerable population.
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Affiliation(s)
- Arvind Srinivasan
- Division of Vascular Surgery, Michael E. Debakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030.
| | - Jorge Miranda
- Division of Vascular Surgery, Michael E. Debakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030
| | - Joseph L Mills
- Division of Vascular Surgery, Michael E. Debakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030
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Shanmugasundaram S, Herman K, Rundback JH. Percutaneous Deep Venous Arterialization in Patients with No-Option Critical Limb Ischemia Performed in an Office-Based Laboratory Setting. J Vasc Interv Radiol 2024; 35:278-284. [PMID: 37839526 DOI: 10.1016/j.jvir.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 09/24/2023] [Accepted: 10/08/2023] [Indexed: 10/17/2023] Open
Abstract
PURPOSE To evaluate the feasibility and safety of percutaneous deep venous arterialization (pDVA) performed in an office-based laboratory (OBL) for patients with no-option critical limb ischemia (CLI). MATERIALS AND METHODS A retrospective chart review was performed of all patients who underwent pDVA using commercially available devices from January 2018 to November 2021 in a single OBL. In total, 22 patients (10 males and 12 females; Rutherford 4, 5, and 6: n = 1, 8, and 13, respectively) were identified with a median follow-up of 140 days. Amputation-free survival, wound healing, pDVA patency, and overall survival were evaluated at 30 days, 6 months, and throughout the remaining follow-up period. RESULTS All patients had undergone failed previous attempts at endovascular arterial reconstruction. At 6 months after procedure, 6.4% of arteriovenous conduits remained patent; 83.3% (10/12) of patients experienced complete or partial wound healing. In addition, 78.6% of patients avoided an above-ankle amputation, and overall survival was 83.6%. Nine patients underwent endovascular reinterventions at 6 months. One mild adverse event and 4 moderate adverse events occurred after procedure, and 1 cardiac death occurred 5 days after procedure. CONCLUSIONS pDVA is safe and feasible in the OBL for patients with no-option CLI. Many patients avoided an above-ankle amputation during the study period despite low overall pDVA patency.
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Affiliation(s)
| | - Kevin Herman
- NJ Endovascular & Amputation Prevention, West Orange, New Jersey
| | - John H Rundback
- NJ Endovascular & Amputation Prevention, West Orange, New Jersey.
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Powell RJ, Mullin CM, Clair DG, Shishehbor MH, Dua A. Comparison of Transcatheter Arterialization of Deep Veins to Standard of Care in Patients with No-Option Chronic Limb Threatening Ischemia. Ann Vasc Surg 2024; 99:50-57. [PMID: 37858666 DOI: 10.1016/j.avsg.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 07/28/2023] [Accepted: 08/04/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Patients with no-option chronic limb-threatening ischemia (no-option CLTI) have limited therapeutic options. The PROMISE II study evaluated, transcatheter arterialization of deep veins (TADV) as a treatment option for no-option CLTI. In the current study patients from PROMISE II were compared to patients from a registry of untreated no-option CLTI patients (CLariTI: Natural Progression of High-Risk Chronic Limb-Threatening Ischemia). METHODS We used propensity matching to compare patients from the PROMISE II prospective study of the TADV intervention with simultaneously enrolled CLTI patients that were note candidates for PROMISE II but were enrolled in to CLariTI natural history registry. Untreated no-option CLTI (CLariTI) patients could either be no-option or patients who did not meet PROMISE II entry criteria. Risk difference between groups was calculated using common risk difference and P values were provided by propensity-score stratified Mantel-Haenszel test. The primary endpoint was amputation-free survival (AFS). RESULTS Diabetes was present in over 75% of patients. All patients had tissue loss and 35-46% had extensive tissue loss (Rutherford 6). The unadjusted AFS at 6 months, was 66.1% by Kaplan-Meier estimate for PROMISE II patients (n = 105) compared to 39.1% in the no-option cohort of CLariTI (n = 121) and 44.0% in the full cohort (no-option and patients not meeting entry criteria combine, n = 180). The treatment group who underwent TADV for no-option CLTI had an absolute difference of 29% improved (P < 0.0001) propensity-adjusted risk difference in AFS and a relative event rate reduction of 45% compared to the no-option control patients. CONCLUSIONS Transcatheter arterialization of deep veins (TADV) resulted in improved 6 month AFS in no-option CLTI patients and appears to be a promising therapy in patients with no-option CLTI.
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Affiliation(s)
- Richard J Powell
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | | | - Daniel G Clair
- Department of Vascular Surgery, Vanderbilt School of Medicine, Nashville, TN
| | - Mehdi H Shishehbor
- University Hospitals Harrington Heart and Vascular Institute, Cleveland, OH
| | - Anahita Dua
- Division of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Roustazadeh R, Gombert A, Krabbe J, Jacobs M, Doukas P. Short-Term Outcomes and Efficacy of Percutaneous Deep Vein Arterialization for No-Option Critical Limb Ischemia: A Systematic Review and Meta-Analysis. Biomedicines 2024; 12:318. [PMID: 38397920 PMCID: PMC10886738 DOI: 10.3390/biomedicines12020318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/13/2024] [Accepted: 01/15/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Percutaneous deep vein arterialization (pDVA) is considered a treatment modality in patients with no-option critical limb ischemia. However, there is still a paucity of evidence regarding its safety and efficacy. DATA SOURCES MEDLINE (via PubMed), Embase and Web of Science databases as well as the CENTRAL registry up to the end of June 2023. METHODS This review adhered to the PRISMA guidelines (PROSPERO registration no. CRD42023445171). The risk of bias was assessed using the methodological index for non-randomized studies (MINORS). Primary endpoints included technical success, overall survival and limb salvage during the follow-up. Amputation-free survival at 30 days, 6 months and 1 year as well as complete wound healing, major adverse limb events and reintervention were investigated as secondary outcomes. RESULTS Five observational studies, comprising 208 patients (142 Rutherford class 5/77 Rutherford class 6), were included. MINORS revealed a low risk of bias. The meta-analysis reached a pooled technical success rate of 96.2% (95% CI: 91.5-98.4), an overall survival of 82.8% (95% CI: 70.5-95.2) and a limb salvage rate of 77.2% (95% CI: 65.2-89.1) during the follow-up. The amputation-free survival at 30 days, 6 months and 1 year was 87.8%, 68.7% and 65.6%, respectively. Furthermore, pDVA resulted in a complete wound healing rate of 53.4% (95% CI: 30.3-76.5). The pooled reintervention rate was as high as 46.7% (37.1-56.3%). CONCLUSIONS PDVA seems a feasible bail-out strategy for patients with no option for routine treatment of CLTI. However, due to the small number of studies, the strength of the evidence is low.
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Affiliation(s)
- Roshanak Roustazadeh
- European Vascular Centre Aachen-Maastricht, Department of Vascular Surgery, University Hospital RWTH Aachen, 52074 Aachen, Germany; (A.G.); (M.J.); (P.D.)
| | - Alexander Gombert
- European Vascular Centre Aachen-Maastricht, Department of Vascular Surgery, University Hospital RWTH Aachen, 52074 Aachen, Germany; (A.G.); (M.J.); (P.D.)
| | - Julia Krabbe
- Institute of Occupational, Social and Environmental Medicine, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Michael Jacobs
- European Vascular Centre Aachen-Maastricht, Department of Vascular Surgery, University Hospital RWTH Aachen, 52074 Aachen, Germany; (A.G.); (M.J.); (P.D.)
| | - Panagiotis Doukas
- European Vascular Centre Aachen-Maastricht, Department of Vascular Surgery, University Hospital RWTH Aachen, 52074 Aachen, Germany; (A.G.); (M.J.); (P.D.)
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Ucci A, Perini P, Freyrie A, Schreve MA, Ünlü Ç, Huizing E, van den Heuvel DA, Kum S, Shishehbor MH, Ferraresi R. Endovascular and Surgical Venous Arterialization for No-Option Patients With Chronic Limb-Threatening Ischemia: A Systematic Review and Meta-Analysis. J Endovasc Ther 2023:15266028231210220. [PMID: 38009322 DOI: 10.1177/15266028231210220] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
BACKGROUND Chronic limb-threatening ischemia (CLTI) is known for its high rates of major amputation and mortality. Conventional revascularization techniques often fail in CLTI patients due to the heavily diseased arteries. Foot vein arterialization (FVA) has been proposed as an alternative technique to provide arterial blood to the foot by using the disease-free venous bed. OBJECTIVES This systematic review and meta-analysis aimed to determine outcomes of surgical FVA (sFVA) and percutaneous FVA (pFVA) at 6 and 12 months post-procedure. DATA SOURCES PubMed, Scopus, Web of Science, and the Cochrane Library databases were searched to identify papers reporting clinical outcomes of sFVA and pFVA published between January 1966 and March 2023. METHODS Databases were searched for eligible studies. A meta-analysis was performed to evaluate the limb salvage rate, overall survival rate, and wound healing rate at 6 and 12 months. RESULTS A total of 27 studies were included, with 753 patients and 793 limbs. Of the included studies, 16 analyzed the sFVA technique and 11 the pFVA technique. Of the included patients, 86.3% were Rutherford 5/6 in the sFVA group versus 98.4% in the pFVA group. The pooled limb salvage rate at 6 and 12 months was 78.1% and 74.1% in the sFVA group and 81.7% and 78.6% in the pFVA group, respectively. Wound healing rates were not reported in the sFVA group. In the pFVA group, the pooled wound healing rates were 48.1% and 64.5% at 6 and 12 months, respectively. CONCLUSION This study showed promising results after FVA among a large population of CLTI patients. In high-risk patients, pFVA is a feasible option with favorable limb salvage and wound healing rates.
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Affiliation(s)
- Alessandro Ucci
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Paolo Perini
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Antonio Freyrie
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Michiel A Schreve
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Çağdaş Ünlü
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Eline Huizing
- Department of Radiology, Spaarne Hospital, Haarlem, the Netherlands
| | | | - Steven Kum
- Vascular Service, Department of Surgery, Changi General Hospital, Singapore
| | - Mehdi H Shishehbor
- University Hospitals Harrington Heart and Vascular Institute, Cleveland, OH, USA
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Montero-Baker M, Sommerset J, Miranda JA. Hybrid superficial venous arterialization and endovascular deep venous arterialization. J Vasc Surg Cases Innov Tech 2023; 9:101160. [PMID: 37404577 PMCID: PMC10315921 DOI: 10.1016/j.jvscit.2023.101160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/24/2023] [Indexed: 07/06/2023] Open
Abstract
We report on two venous arterialization (VA) techniques for treatment of CLTI in patients traditionally considered as having no treatment options for standard arterial endovascular or surgical bypass procedures. Screening and the preprocedural workup findings are outlined as deciding factors in determining a patient's fitness for the two techniques, with a focus on careful preprocedure arterial duplex ultrasound and assessment for vein suitability. Cardiac and infection screening are also factors in determining patient suitability for VA. In addition, radiographic assessment for the presence of medial artery calcification, which is used as a marker of technical difficulty and is a predictor of poor outcomes, is required. Ultimately, anatomic factors are used to determine the decision between hybrid superficial VA and or endovascular deep VA. Those with an occluded anterior tibial artery and suitable great saphenous vein are prioritized to hybrid superficial VA, and those with an occluded posterior tibial artery to endovascular deep VA. Both procedures are described in detail in this report of vascular and surgical techniques.
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Affiliation(s)
| | - Jill Sommerset
- Hope Vascular & Podiatry Clinical Innovation Center, Houston, TX
- Advanced Vascular Centers, Portland, OR
| | - Jorge A. Miranda
- Division of Vascular and Endovascular Surgery, Department of Surgery, Baylor College of Medicine, Houston, TX
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Manninen H. Commentary for Article "Shishehbbor MH et al.: Transcatheter Arterialization of Deep Veins in Chronic Limb-Threatening Ischemia". Cardiovasc Intervent Radiol 2023:10.1007/s00270-023-03493-z. [PMID: 37407740 DOI: 10.1007/s00270-023-03493-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/11/2023] [Indexed: 07/07/2023]
Affiliation(s)
- Hannu Manninen
- Department of Radiology, Kuopio University Hospital, Kuopio, Finland.
- University of Eastern Finland, Kuopio, Finland.
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Kagaya Y, Ohura N, Miyamoto A, Ozaki M. Two stages of salvaging an extensively necrotic foot with chronic limb-threatening ischemia by arterialization of great saphenous vein and free latissimus dorsi musculocutaneous flap transfer for wound coverage with the arterialized vein as the recipient vessel: A case report. Microsurgery 2023; 43:166-170. [PMID: 36547018 DOI: 10.1002/micr.31001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 11/18/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
Patients with chronic limb-threatening ischemia (CLTI) without other options for adequate arterial revascularization could undergo deep (or distal) venous arterialization for limb salvage. Additionally, patients with extensive foot wound with CLTI sometimes require free flap transfer for limb salvage. We herein report a case of successful reconstructive limb-salvage surgery for an extensively necrotic foot with CLTI, using a two-stage operation involving venous arterialization using foot-perforating veins and subsequent free flap transfer (with preservation of the arterialized vein). The patient was a 59-year-old man with CLTI. The patient's right foot had dry necrotic tissue after Lisfranc joint amputation. Only one straight-line to the posterior tibial artery was achieved after endovascular therapies (four times). At the first stage of surgery, an arterial-venous shunt bypass from the superficial femoral artery to the distal great saphenous vein (GSV) (near the foot-perforating vein) was created. Arterial blood supply reached the necrotic area via the foot venous circulation system. At the second stage of surgery, free latissimus dorsi musculocutaneous flap (8 × 27 cm) transfer with preservation of the arterialized vein was performed. The pedicle artery was anastomosed to the bypass graft (end-to-side). The pedicle vein was anastomosed to the proximal stump of the GSV (end-to-end). The flap and residual foot survived completely, at a one-year follow-up postoperatively. An indocyanine green bypass-through angiography revealed the angiosome through the venous arterialization bypass graft, which included the flap; entire forefoot; and partial regions of the midfoot and heel. This two-stage operation might be considered a useful option for limb-salvage and complete wound-healing in patients with severe non-healing wound with CLTI. The two methods could compensate and overcome the problems of either method: incomplete wound-healing after venous arterialization, and the absence of a recipient artery for free flap transfer.
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Affiliation(s)
- Yu Kagaya
- Department of Plastic and Reconstructive Surgery, Kyorin University Hospital, Tokyo, Japan
| | - Norihiko Ohura
- Department of Plastic and Reconstructive Surgery, Kyorin University Hospital, Tokyo, Japan
| | - Akira Miyamoto
- Department of Cardiovascular Medicine, Takatsu Chuo Hospital, Kanagawa, Japan
| | - Mine Ozaki
- Department of Plastic and Reconstructive Surgery, Kyorin University Hospital, Tokyo, Japan
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Sarkar A, Nagarsheth KH. Deep Venous Arterialization for Limb Salvage. CURRENT SURGERY REPORTS 2022. [DOI: 10.1007/s40137-022-00340-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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