SLR- November 2022- Anmol Burmi, DPM
Title: Early experience with venous arterialization for limb salvage in no-option patients with chronic limb-threatening ischemiaReference: Miranda, Jorge A., et al. “Early Experience with Venous Arterialization for Limb Salvage in No-Option Patients with Chronic Limb-Threatening Ischemia.” Journal of Vascular Surgery, vol. 76, no. 4, Oct. 2022, pp. 987–996., https://doi.org/10.1016/j.jvs.2022.05.012.
Reviewed By: Anmol Burmi, DPM
Residency Program: Christiana Care Health Services - Newark, DE
Podiatric Relevance: Limb salvage surgery in the setting of infection is daunting, and typically complicated by peripheral arterial disease. Podiatrists commonly work with vascular surgeons to assess limb salvageability based on peripheral vascularity. We commonly encounter patients with no good options from a revascularization standpoint, who are often relegated to proximal amputations vs palliative wound care with little hope for healing and high risk for eventual proximal amputation. These patients find themselves at high risk for limb loss and death. The authors discuss venous arterialization options for patients with chronic limb threatening ischemia (CTLI) with no feasible conventional interventions possible.
Methods: Patients at Baylor College of Medicine/St. Luke’s Medical Center and UTHSC, San Antonio between 10/2017 and 10/2020 with no option CLTI with a WIfI score of 3 or 4 who were not candidates for open/endovascular arterial revascularization were considered for venous arterialization (VA). Two surgeons performed the preoperative work up and procedures, which included consideration of tibial and/or pedal disease, poor collateralization, and lack of a suitable revascularization target. Patients with acute limb ischemia or a high mortality risk were excluded. Patients initially underwent open techniques before surgeons moved to the endovascular approaches described in the article. A total of 41 patients were included. Outcomes of interest included patency, wound healing, major adverse limb event (MALE) rates, major amputation, and death. Demographics, comorbidities, index limb surgeries, WIfI stage and ambulatory status were also noted. Data was collected prospectively at 1-month, 6-month and 1-year intervals for each patient.
Results: The open and endovascular VA cohorts had a similar 12-month probability of freedom from amputation of 81%, no statistically significant difference between the two cohorts. For the entire cohort, the 12-month primary patency was 28.6%, primary assisted patency was 44.3%, and secondary patency 67%. The MALE rate for overall cohort was 36.5% at 12 months, including a major amputation rate of 17.7% and reintervention rate of 19.5%. Although not statistically significant, there was a trend towards endovascular VA having a higher frequency of reintervention. The amputation rate seen in both cohorts was reduced from the predicted amputation rate by Wifi grade. 46.3% of the patients observed complete wound healing at 12 months and 29.3% of the patient’s required assistance in wound healing with a split thickness skin graft. Four patients (9.8%) died during the study period, two of these due to COVID.
Conclusions: Whether using an open or endovascular approach, VA is an effective option for limb salvage in patients with no option CTLI. The limb salvage and wound healing rates are acceptable/satisfactory for patients that are otherwise destined for major amputation despite the high reintervention rates. This study has several limitations with the biggest being sample size. VA will need to be utilized more frequently to allow for further studies with larger sample sizes. A study with a longer follow-up time on these patients may also be of benefit.