Venous Arterialization: Definition and Clinical Application
Venous arterialization is a novel surgical technique that involves connecting a proximal artery to a distal vein (either deep or superficial), followed by disruption of the venous valves to allow arterial blood to flow retrograde through the venous system to perfuse the foot. 1
Mechanism and Technical Approach
The procedure works by creating an artificial arteriovenous connection that bypasses severely diseased or absent arterial outflow vessels, allowing oxygenated blood to reach ischemic tissue through the venous circulation rather than the traditional arterial pathway. 1
Three Primary Techniques
- Open surgical approach: Direct surgical creation of arteriovenous anastomosis with valve disruption, reporting limb salvage rates of 25-100% across various series 1, 2
- Percutaneous deep vein arterialization (pDVA): Endovascular technique with reported limb salvage rates of 60-71% 1, 2
- Hybrid technique: Combination approach with limb salvage rates of 46-69% 1, 2
Clinical Indication: The "No-Option" CLTI Patient
Venous arterialization is specifically reserved for patients with chronic limb-threatening ischemia (CLTI) who have no viable options for conventional arterial revascularization and face imminent major amputation. 1 This includes patients with:
- Extensive arterial disease precluding standard bypass surgery 3, 4
- Severely disadvantaged or absent tibial arterial runoff (the "desert foot") 4, 5
- Failed prior endovascular or surgical revascularization attempts 4, 2
- Tissue loss or ischemic rest pain with no other treatment alternatives 1
Evidence-Based Outcomes
The 2024 ACC/AHA Peripheral Artery Disease Guideline gives venous arterialization a Class 2b recommendation (Level B-NR), indicating it may be considered for limb preservation when arterial revascularization is not an option and lack of outflow to the foot is observed. 1
Key Performance Metrics
- Limb salvage at 12 months: Pooled rate of 75% across 768 patients in systematic review 1
- Amputation-free survival: 74% at 6 months and 70% at 12 months in the PROMISE I trial 1
- 24-month outcomes: 78% limb salvage rate with 73% complete wound healing in the ALPS Multicenter Study 1
- 30-day mortality: 3.7% in meta-analysis 3
- 1-year survival: 85.7% 3
Important Caveats
The quality of evidence remains limited, with most data derived from retrospective case series and small prospective studies rather than randomized controlled trials. 3, 2 The 2024 guideline acknowledges this is a "novel approach" requiring further investigation. 1
Procedural Considerations
The technique requires creating a common ostium arteriovenous fistula between the target artery (anterior tibial, posterior tibial, peroneal, or plantaris pedis) and corresponding tibial veins, followed by valve lysis to permit retrograde venous flow. 4, 2
Critical Technical Points
- Inflow arteries can range from external iliac to below-knee popliteal vessels 4
- Valve disruption in the foot veins is essential to allow arterial blood distribution 1, 5
- Both autogenous vein and prosthetic conduits (heparin-bonded ePTFE) have been utilized 4, 2
Postoperative Management
Aggressive antithrombotic therapy is crucial, typically involving dual antiplatelet therapy, anticoagulation, or combination regimens to maintain graft patency. 4 The relatively high rates of graft occlusion (primary patency 28.6-87.5% at various time points) necessitate close surveillance. 2
Clinical Context
This procedure represents a last-resort limb salvage option when the only alternative is major amputation. 1, 5 It should only be considered after comprehensive evaluation by a multidisciplinary vascular team has determined that conventional arterial revascularization is truly not feasible. 1