Hybrid superficial venous arterialization limb salvage for “full metal jacket” peripheral arterial stenting and no-option chronic limb-threatening ischemia: A case report

Abstract

Chronic limb-threatening ischemia (CLTI) remains a challenge, especially in the ultra-complex patient population with a history of extensive endovascular revascularization and peripheral arterial stenting. For patients with no conventional revascularization options, endovascular venous arterialization (EVVA) has emerged as a promising salvage option for this “no-option” patient population, due to the small artery disease. However, there are subgroups of these patients that do not even have an option for EVVA. We report a case of an early 70s female patient of successful lower extremity limb salvage with a history of “full metal jacket” peripheral arterial stenting, utilizing superficial venous arterialization technique, in a patient with a refractory deep plantar ulcer and prior transmetatarsal amputation of the left foot. The patient healed within 5 weeks and maintained the ambulatory status, supporting the expanding role of venous arterialization technique variations in complex no-option CLTI.

Introduction

Peripheral arterial disease (PAD) affects over 200 million people globally and is a leading cause of morbidity due to progressive atherosclerosis and limb loss.^1–3 Chronic limb-threatening ischemia (CLTI), the most severe PAD manifestation, presents with rest pain, non-healing wounds, and is associated with high rates of amputation and mortality if not promptly addressed.^4–6 There are subgroups of patients, especially with small artery disease (SAD) or “desert foot,” with no available distal arterial targets for standard surgical or endovascular revascularization, the “no-option” patients, endovascular venous arterialization (EVVA) has emerged as a last-resort technique. ^{5 7–9} However, not all “no-option” CLTI patients with SAD are candidates for EVVA. Here we present a patient with left leg non healing plantar ulcer not an EVVA candidate, secondary to prior endovascular peripheral arteries stenting “full metal jacket” to the tibial level, who underwent successful hybrid superficial venous arterialization (SVA), a novel surgical implementation resulting in wound healing and ambulatory status limb salvage. The structure of this report follows the CARE guidelines. ¹⁰

Case report

Patient profile

A 70-year-old female with long-standing type-2 diabetes, coronary artery disease, peripheral arterial disease, hypertension, and hyperlipidemia, presented with left foot tissue loss and a history of transmetatarsal amputation. The patient had a history of forefoot ulcers two years prior to the procedure and subsequently presented again with non-healing ulcers for over 6 months, which prompted the need for further revascularization. She had undergone multiple previous endovascular procedures and overlapping peripheral arterial stenting from the left superficial femoral artery (SFA) to the proximal tibial arteries, “full metal jacket,” and chronic wound care. Medications aspirin 81 mg, cilostazol 50 mg BID, atorvastatin 80 mg, Insulin 56 U BID, Xarelto 2.5 mg BID, blockers, and insulin. On presentation, she had deep left plantar for ulcer without infection, Rutherford class 6, WIfI 3 3 0 clinical stage 4. ¹¹

Initial evaluation

Physical examination revealed non-healing plantar wound on the left foot (Figure 1(a)), and no local or systemic infection. Femoral pulses were present bilaterally, but no pedal or posterior tibial pulses were palpable. Ankle-brachial indices were unrecordable. Angiography demonstrated occlusive disease in the left lower extremity, absence of patent arterial targets (no tibial, pedal/tarsal arteries), severe SAD consistent with “desert foot” physiology with occluded prior stenting from the takeoff of the SFA all the way within the tibial arteries “full metal jacket” (Figure 1(b)‒(d)).

Figure 1.

(a) White Arrow depicts ulcer deep to muscle level in the plantar aspect of the foot (with prior transmetatarsal amputation). (b) Depicts flow in the common femoral and profundi arteries (white arrows) and no superficial femoral artery flow (white arrow head). (c) Depicts scant contrast opacification of infrageniculate arteries and collaterals (white arrows), as well as stents extending in the tibial arteries (white arrow heads). (d) No meaningful opacification of arteries in the inframalleolar level “dessert foot” picture (White arrow head).

Management decision

The patient had no option for conventional bypass or endovascular intervention, considering she had no anatomical targets and “dessert foot,” and was not amenable to EVVA secondary to “full metal jacket” overlapping arterial stenting from the SFA to the tibial arteries (unable to get endovascular target for venous crossover). Consequently, we proposed a potential alternative to an amputation, a hybrid SVA, since the patient had a widely patent greater saphenous vein (GSV) in line with the plantar venous system. The patient and family provided informed consent after discussion of this novel and investigational procedure of SVA, expected risks, and the absence of alternatives besides major amputation.

Procedural details

Pre-procedure workup included general cardiac clearance, diagnostic angiogram, and vein mapping in the EVVA clinic of Dell Medical School, where the providers assess for the presence of saphenous veins, medial marginal branches, and plantar veins. Under general anesthesia, the left common femoral artery (CFA) was exposed, including the SFA and Profunda arteries. The SFA had prior stents all the way from its origin and extending overlapping stents entering the tibial arteries. Access was obtained inframalleolar to the ipsilateral medial marginal vein (Figure 2(a)) with a 5 Fr micro-puncture system (Cook Medical Inc.) and ultrasonic guidance. The proximal GSV was mobilized and anastomosed to the CFA in a cobra head fashion (Figure 2(b)). After traversing the veins retrograde, we advanced a wire all the way to the venous anastomosis and externalized through a 6 Fr sheath (Terumo Inc.) at the proximal GSV past the anastomosis. The side branches of the GSV were marked with angiographic marking and ultrasonic guidance and ligated with small cutdowns. The venous valves were disrupted using balloon valvotomy to direct arterial flow to the plantar venous plexus. Completion angiography confirmed forward flow into the venous arch (Figure 2(c)). The SVA remained patent throughout the healing phase, with palpable pulses to the foot level, with flow volume ∼62.3 cc/min 2 months after surgery.

Figure 2.

(a) Depicts medial marginal vein access with micropuncture system (white arrow). (b) Greater saphenous vein prepped for cobra head anastomosis with common femoral artery (white arrow). (c) Opacification of inframalleolar venule capillary network (white arrow). (d) Healed plantar ulcer after venous arterialization (white arrow).

Postoperative course

The foot plantar ulcer healed within 5 weeks (Figure 2(d)). The patient was maintained on dual antiplatelet therapy, Xarelto, statin, and local wound care. The patient was able to ambulate, and her quality of life and functional status markedly improved, maintaining independence for activities of daily life with minor support from her family.

Ethics

Written informed consent was obtained from the patient for this publication. All interventions were performed under institutional oversight and adhered to the CARE guidelines. ¹⁰

Discussion

No-option CLTI in patients with SAD is a devastating condition, resulting in major amputations. Although EVVA can be a potential solution for these patients, as we have presented in our work before, ¹² our case highlights another subgroup of patients with additional barriers to revascularization secondary to prior “full metal jacket” overlapping peripheral arterial stenting from the SFA all the way within the tibial arteries. The feasibility of EVVA is impeded secondary to the lack of an anatomical target for arterial to venous crossover connection with EVVA. The SVA technique provides the potential solution for this category of ultra-complex patients. We present in our report the limb salvage results of this procedure, expanding on venous arterialization with EVVA experience.^7,8

Venous arterialization involves diverting arterial inflow into the venous system of the foot with disruption of venous valves and interruption of collaterals, thereby re-perfusing ischemic tissue via the venous plexus and into the capillaries and microcirculation. This technique, first described in the 1970s, has evolved with modern endovascular tools and protocols.^7–9 Recent trials (PROMISE II) with deep vein arterialization using EVVA techniques support a 66% amputation-free survival at 1 year, among early-stage long-term investigations, including our work for 5 years of limb salvage.^8,12 In our era, the accumulation of patients is a product of the endovascular revascularization evolution, emerging as an ultracomplex category of no-option CLTI patients, with full anatomical coverage of the peripheral arteries from the takeoff of the SFA and extending into the tibial arteries, presenting a challenge for the EVVA salvage techniques. In our case report, we are presenting the option to utilize superficial venous arterialization, routing the blood supply from the takeoff of the GSV and into the distal tree, redirecting the flow into the plantar veins and capillary system, as a feasible option for these “full metal jacket” no-option CLTI patients.

The mechanisms of benefit include restoration of microcirculatory pressure, neoangiogenesis, and possible metabolic rescue in chronic ischemic tissue.^2,3 In our patient, rapid improvements in perfusion led to 5 weeks of wound healing of a deep plantar ulcer, paralleling those seen in single-limb reports for patients with options for regular revascularization. The technical challenges are similar to those of EVVA, as they involve properly routing the flow all the way to the plantar venous capillaries, necessitating further investigation and trials. Furthermore, the synergistic effect of wound management, medical management, and optimization is critical, similar to the conventional CLTI patient groups.

Limitations include the lack of long-term patency data and the technical demands of the procedure. Nonetheless, our experience confirms that with careful selection and multidisciplinary care, SVA can salvage limbs, restore function, and substantially improve quality of life for this otherwise “no-option” patient group.

Conclusion

Superficial venous arterialization is a feasible limb salvage option for select patients with “full metal jacket” endovascular stenting, patients with no-option CLTI, desert foot, and improper anatomy for EVVA. This case demonstrates successful limb salvage and functional recovery in a patient with otherwise intractable disease. Ongoing studies are required to validate long-term efficacy and procedural technique optimization. To our knowledge, similar SVA salvage of prior “full metal jacket” CLTI patient has not been reported. Further exploration of this technique is warranted, as the results achieving complete healing of the left foot were very encouraging, providing an alternative solution and developing patient selection guidelines.

Learning Points

• - SVA salvage for no option CLTI not amenable to EVVA is technically feasible and may offer hope for patients with dessert foot and “full metal jacket” arterial stenting.

• - Multidisciplinary case selection and expert opinion are essential to provide alternative solutions.

• - Further research is required to elucidate the mechanisms, refine the technique, assess long-term outcomes, and develop patient selection and management guidelines.