Deep Vein Arterialization for “Desert Foot” A Limb Salvage Technique For Critical Limb Ischemia
Presenter
Khalid B Mohammed, DO, Garden City Hospital, Westland, MI
Khalid B Mohammed, DO, Garden City Hospital, Westland, MI and Patrick B. Alexander, M.D., FSCAI, Ascension Providence Hospital, Southfield Campus, Southfield, MI
Title
Deep Vein Arterialization for “Desert Foot” A Limb Salvage Technique For Critical Limb Ischemia Introduction
Critical limb ischemia can lead to severe complications, including amputations, that can be detrimental to morbidity and mortality. Due to this, limb salvage techniques have been attempted and refined over the years to vascularize limb tissue that still has viability and can protect against a potential amputation. Clinical Case
A 68-year-old female with a history of critical lower limb ischemia and recent intervention of right anterior tibial artery (ATA) 2 months prior as well as a right trans-metatarsal amputation. She presented for infection of right foot stump with gangrene and osteomyelitis. X-ray of right foot showed diffuse bone erosion of tarsometatarsal joints suggestive of osteomyelitis. Angiogram showed right ATA diffuse disease, right posterior tibial artery (PTA) chronic total occlusion (CTO), and patent right peroneal artery (PA). Deep vein arterialization technique. CTO of PTA was crossed using 150cm CXI catheter and Astato wire (unable to cross with Navicross catheter and Command LT/Regalia wires). CXI catheter was advanced in subintimal plane to mid segment. Retrograde posterior tibial vein (PTV) access obtained with advancement of Command LT wire. 6F 120cm Outback Elite Re-entry was placed into right PTA over Command ES wire. 5.0x60mm Pacific balloon was placed from retrograde vein access to level of antegrade arterial Outback catheter position whereafter Outback catheter was used to puncture from subintimal arterial plane into vein with puncture of venous balloon and passage of antegrade Command ES wire into balloon casing where it was externalized through retrograde venous sheath. 4.0x200mm Pacific Xtreme balloon angioplasty of anastomotic site followed by 5.0x15cm Viabahn covered stent. 4.0x38mm Promus stent placed from ostial PTA to just proximal to covered stent. Antegrade right femoral artery access was made as rail length of stents were too short to reach distal targets from left femoral approach. 5.0x15cm Viabahn covered stent placed in PTV distal to previous covered stent. 4.0x100mm Angiosculpt balloon angioplasty of PTV below ankle distal to previous covered stent. 5.0x20mm Pacific balloon angioplasty of anastomotic site. Right PA became acutely occluded from complication of distal emboli resulting in Navicross wire assist and 3.0x80mm Pacific balloon anigioplasty with successful results. Discussion
Deep vein arterialization is rarely attempted. However, this case highlights how patience, and a careful, methodical approach can be potentially limb-saving for a patient who may require amputation otherwise. The patient did well after the procedure with clinical evidence of re-perfusion seen.