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

Autor: Jacopo Scaggiante, Marco Meloni, Roberto Gandini, Stefano Merolla, Laura Giurato, Luigi Uccioli, Daniel Konda
Rok vydání: 2017
Předmět:
critical limb ischemia
Male
medicine.medical_specialty
Percutaneous
Limb salvage
Arteriovenous fistula
Pilot Projects
occlusion
030204 cardiovascular system & hematology
Dialysis patients
Settore MED/13 - Endocrinologia
03 medical and health sciences
0302 clinical medicine
ischemic ulcer
Ischemia
Renal Dialysis
below-the-ankle revascularization
medicine.artery
Occlusion
medicine
Humans
Radiology
Nuclear Medicine and imaging
030212 general & internal medicine
arteriovenous fistula
Vein
desert foot
limb salvage
no-option CLI
plantar vein
posterior tibial artery
subintimal recanalization
vein arterialization
Aged
Treatment Outcome
Limb Salvage
Tibial Arteries
business.industry
Critical limb ischemia
medicine.disease
Surgery
body regions
Posterior tibial artery
medicine.anatomical_structure
medicine.symptom
Cardiology and Cardiovascular Medicine
business
Zdroj: Journal of Endovascular Therapy. 25:127-132
ISSN: 1545-1550
1526-6028
DOI: 10.1177/1526602817750211
Popis: 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.
Databáze: OpenAIRE
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