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11 Re-Entry andRecanalisation Techniques intheEndovascular Management ofPeripheral Arterial Disease
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should be performed under ultrasound guidance in all circumstances; however, whether this is done via a transverse or
longitudinal plane is down to operator preference. Should
the ipsilateral groin be deemed unsuitable, such as in the
presence of a heavily stenosed CFA, surgical scarring, obesity, or active infection, then a contralateral retrograde puncture should be considered.
Once access has been achieved, direct catheter angiography is performed with either iodinated contrast medium or
CO2. In the case of iliac disease, this is commonly performed
with a pigtail catheter and a pump to deliver contrast. In
infra-inguinal disease, angiography is usually performed
through contrast administration via a selective catheter
placed at the level of the lesser trochanter. In instances of
severe disease then it is possible the tibial vessels are poorly
opacied and therefore in such patients the catheter can be
advanced distally (e.g. to the level of the popliteal artery)
before angiography is performed to assess the tibial vessels.
Once the sheath has been advanced over the guidewire, it
should be ushed with heparinised saline and intra-arterial
heparin administered. 3000IU heparin is usually sufcient
for supra-popliteal lesions. Some practitioners advise
5000IU heparin to be administered for a potentially complex
case or if the tibial vessels are to be treated.
Chronic Total Limb Occlusion (CTO)
CTOs can be crossed with either a luminal or subintimal
approach, with little data to suggest one strategy is signicantly benecial over the other. Sometimes in CTO an intraluminal crossing is impossible, and therefore a subintimal
plane must be created. Regrettably, this confers the risk of
the guidewire ending in an extraluminal space and consequent technical failure. Should a subintimal plane be utilised
then primary stenting is often necessitated due to persistent
stenosis, elastic recoil, or dissection. It is worth noting that in
most cases primary patency rates in CTO do not often match
the high technical success rates, with many patients requiring reintervention. Despite this, long-term limb salvage rates
remain high in this patient cohort, with rates of >80% in
many series.
To successfully treat a CTO one must cross the proximal
portion of the lesion, the lesion itself, and then ensure that
they re-enter the lumen distally. Crossing the proximal “cap”
of the occlusion can be difcult if it is calcied, brotic, or if
there are adjacent collateral vessels which the Glidewire may
cannulate preferentially. Initial attempts should be made to
cross the occlusion luminally, usually utilising a “drilling”
approach with the Glidewire with the operator spinning it
between their thumb and forenger to try to help the wire
nd a niche and tract through which it can pass. Should this
be successful, then the wire is accompanied with a support
catheter (such as a Navicross™) to add stability and help
advance it further. It is worth considering the use of a smaller
calibre wire (0.018 or 0.014) should a 0.035 wire be unsuccessful. If there are difculties passing a catheter once purchase has been achieved within the lesion, then segmental
balloon angioplasty can be used to try to open up the channel
to allow distal progression.
Should luminal attempts be unsuccessful, then a subintimal approach can be utilised, thus creating a neo-lumen
between the intima and adventitia to allow blood ow distally. Evidence suggests that despite subintimal angioplasty
not affording as favourable primary and secondary patency
at 12- and 24months (59.1% vs. 78.4% and 56.8% vs. 76.5%
respectively), it still affords high limb salvage rates of 95%.
It is worth noting, however, that the evidence used to support
these claims are of relatively low quality and further randomised control trials are required to support subintimal
angioplasty over other techniques.
This technique is dependent on the operator entering the
subintimal space with a Glidewire and support catheter. It is
a recognised technique to then form a “loop” with the
Glidewire and use this to dissect the subintimal tract, followed by the support catheter (Fig.11.2). The use of a loop
is arguably safer as it decreases the chance of the tip of the
wire becoming extraluminal. Ideally, the wire will spontaneously become luminal once the CTO has been crossed, however in some cases this will not occur, and a re-entry device,
such as an Outback® (Cordis, FL USA) catheter, is required
to break back into the luminal space. Once it has been proven
that one is intra-luminal through the delivery of contrast
through the support catheter, then the support catheter can be
exchanged for an appropriately sized angioplasty balloon to
dilate the channel and allow for increased blood ow distally. Should there be a technical failure due to persistent stenosis or elastic recoil then primary stenting should be
considered with a bare-metal stent (unless the treated vessel
ruptures). The stent should be long enough to cover the entire
length of the CTO from “normal vessel to normal vessel”.
Regarding sizing, it is advised that the diameter of the stent
is 10% larger than the measured vessel diameter with postdilation to 1mm below the stent size; for example, a 5mm
vessel would require a 6mm stent which is post-dilated with
a 5 mm angioplasty balloon. Unlike primary angioplasty,
when post-dilating a stent the balloon is simply required to
be inated to the nominal pressure and then immediately
deated.
Subintimal Tracking andRe-entry (STAR)
Technique
A modication of the STAR technique is Direct Tip Injection
in Occlusive Lesions (DIOL). This method utilises the
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Fig. 11.2 Subintimal wire
passage
G. Makris et al.
hydro-dissection of the subintimal plane via the injection of
contrast media through a micro- or balloon catheter. This
technique allows the operator to visualise the created microchannel as well as creating space to advance the necessary
kit. Should this be utilised in an antegrade fashion, then it
may result in iatrogenic dissections which extend beyond the
target re-entry point, to compress the true lumen, and compromise ow distally in the crural vessels. In these instances,
a smaller, gentle injection of 1-2mL of contrast media should
be used. Conversely, when using an antegrade approach,
forceful injection of 5mL of contrast media may be required
to both visualise the tracts and increase the space within the
subintimal plane. Once this has been achieved then attempts
to re-enter the lumen and complete the procedure may be
attempted.
Sharp Recanalisation
Chronic total occlusions frequently have a calcied proximal “cap” which prevents the interventionalist from traversing the lesion with conventional guidewires and
catheters. Should it prove impossible to cross the lesion
then sharp recanalisation can be considered. In these circumstances, the guidewire is removed and turned around,
with the practitioner advancing the stiff, back end of the
wire into the occlusion. The rationale of this is to pierce the
stiff cap before the wire is removed once more and the soft
end is used to cross the lesion and continue with the procedure. One should be satised that the cap has been pene-
trated by either feeling a “give” in the wire once it has
progressed or noting its movement through the occlusion
on uoroscopic imaging.
Once you are sure you have traversed the proximal cap,
advance your crossing catheter, (e.g. Navicross®), just into
the occlusion before turning the wire back around to its correct direction. Once you have done so rapidly rotate the wire
within your ngers to try to nd a channel through which
you can advance your equipment. If this is unsuccessful,
then a loop can be formed within the wire to dissect the subintimal plane. Loops are not only useful in giving your wire
stability to progress the wire, but also, they have a decreased
chance of vessel perforation and the wire ending up in the
perivascular soft tissues. This is not necessarily a serious
consequence; however, guidewires prefer to follow a path of
least resistance and, should this be through a perforated vessel wall, then you may be unable to cross the lesion and
therefore have to either perform a new puncture or abandon
the procedure entirely.
There are undoubtedly risks in performing such a manoeuvre, primarily that using the stiff end of the wire confers a
risk of both vessel perforation and dissection; potentially
conferring increased morbidity and mortality upon the
patient. Usually, vessel perforations at the level of the SFA
and below are of little clinical concern due to the immediate
tamponade effect of adjacent musculature and fascial planes.
Perforations at the level of the CFA and above can be catastrophic due to a lack of adjacent compressive tissues, resulting in pseudoaneurysm formation and potential death from
exsanguination.
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CTO Crossing Devices
Re-entry Devices
It is often difcult to re-enter the true lumen when utilising a
subintimal approach, with reported failure rates of up to 26%
and, when successful, it may only be possible to become
luminal distal to the vessel reconstitution point, with consequent sacrice of signicant collateral vessels. These challenges have inspired the development of re-entry devices
such as the Outback ® (Cordis), BeBack (Bentley), Pioneer
(Philips), Offroad™ (Boston Sci) and Enteer™ (Medtronic)
catheters, to name a few. Evidence suggests that the use of
re-entry devices have similar outcomes in subintimal angioplasty when compared to standard catheters (88.3% when
using re-entry devices vs. 92.5% without) with similar rates
of complications.
Furthermore, using these devices can reduce the procedural time (and thus radiation dose), the number of guidewires required, and the volume of contrast media used when
compared to other techniques such as subintimal arterial
ossing with antegrade and retrograde intervention
(SAFARI). This confers not only a benet to patients but also
to healthcare providers given the decreased cost of treating
CTO.
Outback ® (Cordis)
This catheter is designed to work over a 0.014 wire with the
Outback requiring a 6Fr sheath to accommodate the device.
The catheter itself has a hydrophilic coating to afford easier
passage through the subintimal plane and a 22G nitinol reentry cannula. The Outback catheter has “L” and “T” radiopaque markers to allow for the orientation of the catheter
under uoroscopic guidance, thereby mitigating the need for
intravascular ultrasound (IVUS).
Once the CTO has been crossed subintimally with an
0.014 wire, advance the tip of the device to the desired reentry point. Once you are satisfactorily positioned, rotate the
catheter so that the “L” marker is facing the true lumen. At
this point, the image intensier must be positioned so that
you have a 90-degree orthogonal view of the vessel before
rotating the device so the “T” marker en masse. At this point,
the wire should be withdrawn by approximately 5 centimetres into the device before the nitinol cannula is advanced
into the true lumen. When you are satised you are luminal
once more, retract the cannula and remove the Outback®
device before proceeding to treat the occlusion.
Good technical results with the Outback ® system have
been reported in the treatment of lower limb CTO; however,
difculties persist with becoming luminal once more in the
presence of signicantly calcied distal re-entry sites.
BeBack (Bentley)™ Catheter
The BeBack™ Crossing Catheter (Bentley) is similar in
design and function to the above-described OutBack re-entry
device. It comes in two calibres, a 2.9Fr catheter requiring an
0.014 wire and 5Fr sheath, or a 4Fr catheter which needs at
least a 0.018 wire and 6Fr sheath. As with the OutBack system, the GoBack Crossing Catheter can be used entirely
under uoroscopic guidance without the need for IVUS.
Once a lesion has been crossed subintimally, the nitinol needle at the tip can be deployed to up to 11mm in the 4Fr system, and 7mm in the 2.9Fr system. The needle initially exits
the catheter tip in a straight line, however, is designed to
curve to allow for directional deployment as it is advanced
further. To facilitate precise deployment, there is a “C”
shaped radiopaque marker within the body of the catheter,
with the open portion of the “C” corresponding to the needle
angle. As with the other re-entry devices, once the needle has
penetrated the lumen, the guidewire can be advanced, and
the re-entry catheter exchanged for the necessary kit to complete the patient’s treatment.
Pioneer Plus (Philips)
The Pioneer Plus Re-entry Device (Philips US) is a re-entry
catheter which has a 20MHz intravascular ultrasound transducer at its tip. It is a monorail catheter using a 0.014 system
and requiring a 6Fr sheath. The rationale for having an
adjunctive IVUS attached to the catheter tip is to allow for
accurate assessment of the intima at the level of re-entry and
to demonstrate the true lumen before the advancement of the
nitinol cannula through the subintimal layer before becoming luminal once more. Reported outcomes with the Pioneer
device are good, with evidence suggesting that this re-entry
system has an average re-entry time of 6–10min with technical success rates of 95–100%.
The mechanism of action is similar to the Outback ® catheter. Firstly, one must traverse the CTO via the subintimal
plane before determining a suitable re-entry site. Once this has
been achieved, IVUS is performed to allow to direct the cannula towards the true lumen prior to the advancement of a nonhydrophilic 0.014 wire into the vessel lumen. This can be
ascertained as the true lumen is at the 12 o’clock position on
IVUS, and the lumen diameter can be measured with the reticule displayed on the IVUS monitor. Once the operator is
happy with both the position and diameter of the true lumen,
the red handle is twisted to the correct needle deployment
length before advancing the blue needle deployment ring
quickly to advance the nitinol cannula into the true lumen.
When the cannula is within the vessel lumen, the needle is
retracted and the catheter removed before the CTO is treated
with angioplasty or stenting, depending on technical success.
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ORoad™ Re-entry Catheter System
The OffRoad™ catheter (Boston Scientic, USA) uniquely
has a 5.4mm conical angioplasty balloon just proximal to its
tip. When inated, this allows the operator to dilate the subintimal tract and create more space to manoeuvre the piercing needle into the vessel lumen. The Re-ROUTE trial
demonstrated that this catheter was effective in navigating
approximately 85% of CTOs. The catheter itself operates via
a dual-wire system: the main catheter requires a 5Fr sheath
and is designed for use with a 0.035 guidewire. The microcatheter lancet slides through the main catheter body with a
diameter of 2.4Fr and facilitates an 0.018 wire (or smaller).
As with the other described re-entry devices, the catheter is
to be advanced past the occlusion in the subintimal plane
before re-entry and passage of necessary kit. Bear in mind
with this dual-wire system that it will be the 0.18 wire which
ultimately ends up in the true lumen when considering which
equipment, you will use for further intervention.
Enteer Re-entry System
The Enteer™ system (Medtronic) is similar in function to
that of the aforementioned OffRoad re-entry device in that it
has an angioplasty balloon at its distal end. This device, however, has a straight angioplasty balloon which is more similar
to a standard PTA balloon in shape when compared to the
conical OffRoad balloon. The balloon is inated to dilate the
subintimal tract. As with many of the other systems, it is an
over-the-wire system which utilises either a 0.014 or a 0.018
guidewire. The supplied wire with this system has a 28° curvature at the working end to allow for the operator to direct it
towards and puncture the true lumen.
SAFARI andCART Techniques
Subintimal arterial ossing with antegrade and retrograde
intervention (SAFARI) is a treatment consideration when
other re-entry techniques fail. Firstly, imaging must be
obtained to ascertain the feasibility of retrograde arterial
access, be that ultrasound or through direct angiography. The
foot vessels are most frequently used, the dorsalis pedis is
commonly accessed within the level of the mid-navicular or
slightly above the ankle mortice, and the posterior tibial
artery posterior to the medial malleolus or immediately
superior to the ankle joint. Fluoroscopic access is usually
achieved at the lower third of the interosseous membrane. It
should remain a consideration that haemostasis is more difcult to achieve after accessing the peroneal artery due to the
lack of a deep bony prominence to manually compress
against with a subsequent risk of compartment syndrome
secondary to haemorrhage.
A micropuncture needle is used to puncture the chosen
vessel before the advancement of the supplied dilator (usually 3Fr) over the guidewire. In some instances, a longer
micropuncture dilator can be used in instances of more heav-
ily calcied vessels to disrupt calcic plaques and facilitate
the passage of your kit. Once access has been secured, an
exchange-length (300 cm) 0.018 or 0.014 wire can be
advanced retrogradely towards the occlusion. In some
instances, the occlusion can be crossed luminally from
below; however, in many cases, subintimal recanalisation is
required from this retrograde approach. Should the vessel be
amenable to it, then a 4Fr sheath or catheter can be used to
add stability to a crossing catheter. It is often a sensible idea
to administer GTN in 100mcg-200mcg aliquots (should the
patient’s blood pressure permit) and to maintain an ACT over
250s to decrease the likelihood of thrombosis formation in
smaller vessels, particularly those with a lumen diameter less
than 1.5mm.
Once the retrograde wire has crossed the occlusion and
re-entered the true lumen then it may be snared from the
antegrade access before being pulled through the sheath, giving continuous wire access throughout the length of the vessel. Should the antegrade catheter already be within the same
subintimal plane as your retrograde wire, then this too can be
cannulated to allow wire passage. Woefully, in many
instances both accesses, (despite being in the same subintimal plane), do not communicate with one another. Should
this occur, there are a few techniques to help navigate out of
this predicament. Firstly, a new antegrade access can be
attempted to have communicating subintimal tracts or a reentry catheter can be used to attempt to enter the true lumen.
If these are unsuccessful, then a reverse controlled antegrade
and retrograde subintimal tracking (CART) technique can be
trialled. This procedure involves the passage of a 4 mm
angioplasty balloon over the antegrade wire and inating it
to disrupt the obstructing intimal layers to allow throughand- through access. One nal consideration is to attempt
sharp recanalisation using the back end of a guidewire, however, this is not a risk-free manoeuvre as previously discussed in this chapter (Fig.11.3).
Percutaneous Deep Venous Arterialisation
Percutaneous deep venous arterialisation is a novel treatment
for patients with CLI who are not suitable for bypass surgery
or standard PTA due to a lack of suitable distal runoff vessels. The crux of the treatment is to supply oxygenated blood
to the capillary bed using a vein as the delivery method via
an iatrogenic arteriovenous stula.
The procedure entails the use of a proximal, antegrade
arterial puncture and a distal, retrograde venous puncture.
Both angiography and venography are performed to prove
the patient’s anatomy is suitable and to demonstrate the
shortest point between the target artery and vein to facilitate
the formation of the stula. Usually, a 7Fr sheath is sufcient
in the arterial segment, and a 5Fr sheath for the vein.
Once the shortest distance has been identied, catheters
are advanced within the artery and vein to sit adjacent to one
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Fig. 11.3 The SAFARI
technique demonstrating
snaring a subintimal wire to
allow for a through-andthrough wire
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another at this point. A re-entry catheter is then used under
uoroscopic of IVUS guidance to exit the artery and enter
the vein. Once this through-and-through access has been
obtained, a guidewire is advanced from the arterial to the
venous segment. Valvulotomy is performed on the vein,
often with a suitably sized angioplasty balloon before the
covered stents are deployed from the arterial anastomosis
through the venous segment to occlude any collateral vessels.
Should persistent, large collaterals be present then these can
be selectively embolised.
The evidence for the success of percutaneous deep venous
arterialisation is somewhat limited, primarily due to it being
a rarely performed procedure. The available data suggests
primary patency rates of approximately 30% at 6months and
40% at 10-month follow-up, with limb salvage rates of up to
70%. This preliminary data therefore may make this an
attractive option in patients with no other option.
Possible Complications
Complications from PTA are most commonly from achieving haemostasis at the end of the procedure or intra-operative
complications secondary to technical aspects during the procedure itself. Evidence suggests that major complications
such as vessel thrombosis or rupture occur in approximately
5% of cases, with 2.5% of patients undergoing PTA requir-
ing surgery and an overall limb loss and mortality rate of
0.2%.
Improper haemostasis can be secondary to the puncture
being oblique within the vessel wall or it being too proximal
or distal and therefore not facilitating adequate compression
once the sheath has been removed. In these instances, complications can include a haematoma at the access site or
pseudoaneurysm formation. Manual haemostasis is the most
common method of closure of the arteriotomy; however,
ultrasound-guided compression can be of use in decreasing
such complications, especially should a brachial artery puncture be performed. Should a pseudoaneurysm form then
manual compression can be utilised in the immediate postprocedural period, however, should it be large (>3cm) or
persistent then ultrasound-guided thrombin injection or surgical repair may be required.
Complications may also arise from vascular injury during
the procedure, namely dissection or rupture. Dissection is in
essence the stripping of the intima or media of the arterial
wall and is easily identied uoroscopically as a ap within
the lumen. The commonest causes of dissection are either
angioplasty or improper manoeuvring of the kit, such as
advancing a catheter without the use of a guidewire. In most
instances a dissection can be managed with prolonged angioplasty, however, should this not resolve the situation then an
uncovered stent can be deployed over the dissection ap.
Care must be taken to occlude the entrance of the false lumen
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G. Makris et al.
to prevent distal extension of the dissection. Should a dissection be ow-limiting then it can occlude the vessel with consequent acute limb ischaemia if it is not appropriately
managed.
Vessel rupture is often secondary to either oversizing the
angioplasty balloon or performing PTA on a heavily diseased
(calcied) vessel. The management of a vessel rupture is
dependent on the location, as an iliac rupture can result in
life-threatening retroperitoneal haemorrhage; however, a
rupture within the SFA or crural vessels is unlikely to confer
such serious consequences due to tamponade from the adjacent fascial planes. Clinically a rupture can present as signs
of haemodynamic compromise with persistent pain postangioplasty. Radiologically a persistent extravascular contrast “blush” will be seen adjacent to the rupture demonstrating
contrast extravasation. Should a rupture occur within the
iliac arteries then covered stenting is advised as a matter of
haste. One should anticipate this potential complication and
have suitable stents (such as a Viabahn™) present in the
room as well as a sheath large enough to facilitate its deployment. Upon discovering a rupture, the angioplasty balloon
should be deployed to cover it immediately and tamponade
the bleed whilst the stent is prepared.
Thrombosis and embolisation are potentially limbthreatening consequences of endovascular management of
PAD, hence why these patients receive intra-arterial heparin
once the sheath is inserted. Thrombus formation can be difcult to discern from vasospasm at the time of the procedure,
with both affording an irregular appearance to the vessel
lumen. Should a complete occlusive thrombus occur then
there will be an abrupt termination of contrast ow distal to
it, with contrast reux seen proximally. In a non-occlusive
thrombus, the initial management attempts can be to aspiration with a catheter or, prolonged balloon angioplasty to try
to compress it against the vessel wall. Chemical thrombolysis involves intra-arterial Alteplase® at a dose of 5mg at the
time of the thrombosis before consideration of performing
catheter-directed thrombolysis with a Cragg-Macnamara
catheter over 24 h and up to 72 h. Patients who require
catheter- directed thrombolysis will need to be admitted to
the intensive care unit for monitoring due to the risk of lifethreatening haemorrhage. Contraindications to thrombolysis
include recent intracerebral haemorrhage, intracranial neoplasm, active bleeding, and uncontrolled hypertension.
Should the patient not be suitable for catheter-directed
thrombolysis, then Rheolytic thrombectomy (e.g., with an
Angiojet™ system) can be performed which confers
decreased morbidity and mortality to catheter-directed
thrombolysis, however, this treatment is dependent on the
operator being able to advance a guidewire past the thrombus
itself. In instances where catheter-directed thrombolysis and
mechanical thrombectomy are not practical then surgical
thrombectomy or bypass is advised should the patient be t.
Perioperative Care andSurveillance
The perioperative care of patients who have undergone PTA
or stenting for PAD is often dependent on the complexity of
the procedure, the size of the sheath used, and whether a closure device was used. In instances of manual haemostasis,
then prolonged bed rest is advised (up to 4h) to decrease the
chances of signicant haemorrhage from the arteriotomy
site. Recovery staff are advised to check the patient’s observations and observe the puncture site frequently during this
period to assess for haematoma formation or active bleeding
which may require urgent intervention. The use of a closure
device (such as Angioseal™ or Prostyle™) speeds up the
recovery process allowing for expedited mobilisation as the
arteriotomy site has been mechanically closed.
Other considerations regarding recovery are if the patient
has received any sedation such as fentanyl or midazolam or
if the case was performed under general anaesthesia. In such
instances, further monitoring is advised in the postprocedural period to ensure there are no complications from
the use of such medications, such as aspiration or respiratory
suppression.
In the absence of complications, and if the patient is
deemed functionally t to do so, then most patients can be
discharged home as a day case once their recovery period is
over.
Case Presentation
An 0.018 guidewire was navigated into the DP micropuncture catheter, through the AT and into the distal SFA via a
subintimal approach. The distal sheath was cannulated, and
the wire passed proximally to allow for a through-andthrough wire. Angioplasty was performed of the AT with a
2mm×220mm and subsequently 3mm×120mm angioplasty balloon to good effect. The SFA-popliteal occlusion
was addressed with a 5mm×120mm angioplasty balloon
before deployment of a 5mm×120mm stent distally and a
6 mm × 80 mm stent proximally and post-dilated with a
5mm angioplasty balloon. Satisfactory post-stenting angiographic appearances. Manual haemostasis was achieved with
no immediate complications (Fig.11.4).
11 Re-Entry andRecanalisation Techniques intheEndovascular Management ofPeripheral Arterial Disease
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Fig. 11.4 LEFT: The through-and-through wire from the DP puncture
through to the CFA sheath facilitating angioplasty of the SFA-popliteal
occlusion. RIGHT: Post-angioplasty angiographic run demonstrating
patency throughout
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101
Deep Venous Arterialisation
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BasilZiaKhan, ThomasBarge, andRamanUberoi
12
Deep Venous Arterialisation Case at Oxford
A 53-year-old male patient with a past medical history of
type II diabetes mellitus, asthma, severe peripheral vascular
disease, and right middle toe amputation had repeated hospital admissions for infected diabetic foot ulcers.
The patient underwent a total of three right-sided infra
popliteal angioplasty intervention. The initial angioplasty
demonstrated a patent supercial femoral (SFA) and popliteal artery with a three-vessel run off; however, there were
multifocal stenoses limiting ow within the posterior tibial
artery (PTA). The anterior tibial artery (ATA) and peroneal
arteries also demonstrated multifocal stenoses without limiting ow. The proximal PTA underwent a 2mm angioplasty.
Despite treatment, there was no improvement in ulcer healing, subsequent infra popliteal angioplasties demonstrated
progression of disease with new occlusion of the distal ATA
and PTA.These were not treatable with conventional endovascular techniques and a decision was made to perform a
deep venous arterialisation (DVA).
Anterograde arterial access was made at the SFA and retrograde venous access was made into the distal PTV. The
proximal PTA was dilated. This was followed by creation of
a stula between the proximal PTA and PTV using outback.
Two 5×10cm Viabahn stents were placed extending across
the stula into the distal PTV.Subsequent venoplasty up to
5mm was done to the level of the deep venous arch to destroy
the valves. During the procedure the stula occluded which
was treated successfully with thromboaspiration and further
plasty. Final run demonstrated adequate ow through the
DVA circuit (Fig.12.1).
B. Z. Khan · T. Barge · R. Uberoi (*)
Department of Interventional Radiology, Oxford University
Hospitals NHS Foundation Trust, Oxford, UK
e-mail: basil.Kahn@ouh.nhs.uk;
Tom.barge@ouh.nhs.uk; raman.uberoi@ouh.nhs.uk
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
G. Geroulakos et al. (eds.), Mastering Endovascular Techniques, https://doi.org/10.1007/978-3-031-42735-0_12
103
104
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B. Z. Khan et al.
a
b
c
Fig. 12.1 (a and b) demonstrate vascular appearances prior to intervention. (c) demonstrates a satisfactory appearance of a patent DVA circuit
Introduction
Chronic limb-threatening ischaemia (CLTI) is a common
cause for patients to present to an interventional radiology
service. Management revolves around improving arterial
inow, ultimately to improve tissue perfusion. In the lower
limb iliofemoral disease is commonly treated either endovascularly or via surgical bypass, whilst endovascular therapy
dominates in the infra-popliteal segments. Angioplasty,
including re-canalisation of chronic total occlusion of crural
vessels, is the mainstay of treatment options. However, in
some patients, there may be no suitable targets for recanalisation. This is usually due to a combination of total
occlusion of all crural arteries, and no suitable distal run-off
into the foot, usually due to end stage plantar atherosclerotic
disease. Blood ow to the foot is via small, unnamed collaterals, with little macroscopic ow demonstrated on angiography, giving the appearances of a so called ‘desert foot’. It
is this patient cohort that deep venous arterialisation (DVA)
may be suitable.
DVA involves the creation of a stulous connection
between a crural artery and vein. The aim is to cause retro-
12 Deep Venous Arterialisation
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105
grade ow down a crural vein into the foot, fundamentally to
increase the oxygenation of the blood pool in the capillary
bed. The extensive venous collateral drainage pathways from
the lower limb facilitate outow, with reversal of ow in the
arterialised vein not signicantly impacting on venous drainage. The origins of DVA dates back to 1881, when Francois
Frank, a French physiologist performed the rst arteriovenous anastomosis in dogs [1], soon followed the rst in
human procedure in 1894 [2]. The rst pedal vein arterialisation was recorded in 1912 [3]. Since its introduction over a
century ago the procedure has been rened, with Sheil publishing the rst case series of DVA procedures in 1977 [3]. A
total of 6 patients with CLTI underwent a DVA where a connection was made between the long saphenous vein and dorsal venous arch [4], reporting improvement in pain and tissue
healing in 5 out of the 6 patients. Whilst early DVAs were
done using an open surgical technique, they are now mostly
done using an endovascular approach.
Indications, Contraindications andWork
UpforDVA
DVA has mainly been performed on patients with CLTI
where standard revascularisation options have failed or are
not technically suitable. Candidates for DVA are often placed
in classes 5 and 6 of the Rutherford criteria or stages 3 and 4
of the Fontaine criteria.
In 2014, a new classication system known as Wound,
Ischaemia, Foot Infection (WIfI) was introduced by the
Society for Vascular Surgery (SVS). The aim of this classication is to provide staging of a patient with CLTI in terms of
amputation risk and benet of revascularisation. The higher
the overall WI score the greater the amputation risk and
benet of revascularisation (Tables 12.1, 12.2, and 12.3).
Candidates for DVA must demonstrate good arterial
inow up to the point of crossover/occlusion hence the
importance of pre interventional angiographic assessment of
the foot and leg. Inow may be optimised during the DVA
procedure, but signicant proximal arterial disease may be a
contraindication to DVA.Furthermore, structures such as the
deep venous arch must be patent and good venous outow
must be established. This can be achieved via duplex ultrasound assessment, magnetic resonance imaging or conventional venography and a lack of acceptable venous outow
would be a contraindication. Extensive tissue loss, or the
combination of tissue loss and signicant rest pain may also
be relative contraindications.
DVA may be performed under local anaesthesia and conscious sedation, or under general anaesthesia. Patients
typically require an overnight stay, although as experience in
the procedure increases, it may be possible to perform these
as a day case. Given the cohort of patients DVA is performed
Table 12.1 Wound grading from WIfI classication adapted from
Mills JL Sr etal. [5]
Wound
0 Pain at rest, no ulcer or gangrene
1
Small shallow ulcer on leg/foot salvageable with single−/
double-digit amputation or skin coverage. No gangrene
2 Deep ulcer exposing bone/tendon, joint in foot or leg. Salvageable
with > three-digit amputation or trans metatarsal (TMA)
amputation with skin coverage. Shallow heel ulcer with no
calcaneal involvement. Gangrene limited to digits
3 Deep ulcer involving forefoot and mid foot. Full thickness heel
ulcer with/without calcaneal involvement. Extensive gangrene.
Treatable with reconstruction of foot or non-traditional TMA
Table 12.2 Ischaemia grading from WI classication adapted from
Mills JL Sr etal. [5]
Ischaemia
Ankle systolic pressure
Grade
(mmHg)
0 100 and above
1 70–100 40–59 0.6–0.79
2 50–70 30–39 0.4–0.59
3 <50 <30
Table 12.3 Foot infection grading from WI classication adapted
from Mills JL Sr etal. [5]
Foot Infection
0 No signs or symptoms
1 Local features of infection conned to skin
2 Localised infection extending to deeper structures
3 Localised infection with features of systemic inammatory
response syndrome
Toe pressure
(mmHg)
≥60 ≥ 0.80
Ankle-brachial
index
≤0.39
on, it may be challenging for them to remain still for a prolonged period during the procedure, which can be long.
Consequently, general or regional anaesthesia may be
required. This may be a complicating factor due to the frequently encountered medical co-morbidities, which may
deem some patient’s unacceptably high risk. An alternative
consideration is the use of regional limb nerve blocks, which
may provide excellent pain relief for the patient as well as
ensuring the operative limb remains still, which is crucial for
certain technical steps for the procedure.
Patients require standard workup for angioplasty and/or
anaesthesia review pre-operative.
Open Surgical Approach toDVA
DVAs were initially performed with an open surgical technique and may at times still be performed. Common arterial
targets include the tibial, popliteal, supercial or common
femoral arteries, and venous targets include the posterior
tibial vein or dorsal venous arch. The arterial and venous
access points may then be connected by means of a venous
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