SLR - June 2023 - Christopher Zimmer, DPM
Title: Transcatheter Arterialization of Deep Veins in Chronic Limb Threatening IschemiaReference: Shishehbor MH, Powell RJ, Montero-Baker MF, et al. Transcatheter Arterialization of Deep Veins in Chronic Limb-Threatening Ischemia. N Engl J Med. 2023;388(13):1171-1180. doi:10.1056/NEJMoa2212754
Level of Evidence: II
Scientific Literature Review
Reviewed by: Christopher Zimmer, DPM
Residency Program: Baylor Scott and White Medical Center, Temple, Texas
Podiatric Relevance: In the literature there is approximately 20% of individuals with severe critical limb ischemia who have no endovascular or open bypass surgical options. This consequently leads to more proximal amputation above the level of the ankle. However, there is a new surgical option called Transcatheter Arterialization which is performed percutaneously (US guided pedal vascular access with stent placement in the proximal tibial artery and vein) and delivers arterial oxygenated blood to the pedal venous arch in order to prevent against amputation. This is a novel approach to limb salvage and can significantly help the podiatric surgeon in preserving as much of the patient’s native anatomy as possible.
Methods: PROMISE II was a prospective, single group, multicenter study performed in order to address patients with nonhealing ulcers who were not surgical or endovascular revascularization candidates. The primary end point was amputation free survival. Defined as a composite of freedom from above-ankle amputation or death from any cause at 6 months. Secondary end points were patency of the circuit, limb salvage, change in Rutherford classification, technical and procedural success, healing of the wounds, and wound area.
Results: 105 patients were enrolled in the study. Most of the patients had several conditions which included diabetes, hypertension, dyslipidemia, and approximately 74% of the patients had undergone previous revascularization (angioplasty and bypass) procedures on the operative limb. All of the patients had either frank gangrene, a nonhealing ulcer, or were classified as Rutherford class 5 or 6. Transcatheter arterialization was successful in 104/105 patients (99.0%) with no adverse device events.
Conclusions: In the healthcare system there continues to remain a staggeringly high number of patients with chronic limb threatening ischemia who have poor quality of life and life expectancy. Transcatheter arterialization provides a valid option for revascularization in patients who were previously assigned to undergo primary amputation. This in turn can result in a higher quality of life and decrease the possibility of social isolation, depression and the economic burden of amputation. Transcatheter arterialization of the deep veins is a safe and highly successful procedure in individuals who have chronic limb threatening ischemia with no other revascularization surgical options.