CC BY-NC-ND 4.0 · The Arab Journal of Interventional Radiology 2018; 02(03): S18
DOI: 10.1055/s-0041-1730692
Abstract

In situ Arterialization of the Posterior Tibial Vein for Management of Critical Limb Ischemia Using Outback Re-Entry Catheter-Technical Report

Ibrahim Abulaziz Alghamdi
King Faisal Specialist Hospital And Research Center, Jeddah, Saudi Arabia
,
Zia Zergham
King Faisal Specialist Hospital And Research Center, Jeddah, Saudi Arabia
,
Donald John Bain
King Faisal Specialist Hospital And Research Center, Jeddah, Saudi Arabia
,
Hany Mohammed Hafez
King Faisal Specialist Hospital And Research Center, Jeddah, Saudi Arabia
,
Salah Saleh Kary
King Faisal Specialist Hospital And Research Center, Jeddah, Saudi Arabia
,
Majed Ahmed Ashour
King Faisal Specialist Hospital And Research Center, Jeddah, Saudi Arabia
› Author Affiliations

Background: Critical limb ischemia (CLI) is considered a serious public health burden in the Gulf region especially with the high incidence of diabetes mellitus in this region. Several endovascular and open surgical methods are used to preclude amputations or mitigate the morbid consequences. Endovascular arterialization of the deep veins for improving the distal blood flow to the lower limb has recently been used in CLI patients. In this paper, we describe a new endovascular technique for in situ arterializations of the posterior tibial vein using Outback (Cordis) re-entry device. We discuss the patient selection criteria for arterialization of leg veins and discuss the outcome. Methods: We reviewed the demographic information, peripheral arterial disease risk factors, clinical history, treatment history, and images of the patient referred for consideration of arterialization of the leg veins. Images from PACS are used to describe the novel technique of lower limb venous arterialization. Results: A 52-year-old male patient, diabetic and heavy smoker, presented with a non-healing ulcer and rest pain in the right foot. He had a surgically amputated big toe. Imaging showed below knee occluded arteries with a patent dorsalis pedis and foot arteries. He was managed several times by endovascular methods with recanalization of the anterior tibial artery (AT). The AT was treated with a standard balloon, drug-coated balloons, short focal stent to maintain patency over 2 years. The patient presented with recurrent symptoms of CLI and occluded AT after almost every 3 months of intervention. A surgical femoral distal bypass was also done which occluded. The latest endovascular intervention was 5 months back with quick recurrence. His case was discussed in the multidisciplinary vascular meeting, and he was offered either surgical amputation or a trial of endovascular arterialization of the leg veins. The patient decided to go with the latter. The right common femoral artery was accessed in an antegrade fashion, and a 7-French sheath was inserted. First, the re-occluded AT artery was recanalized and treated with 3 mm standard balloon. The posterior tibial vein (PTV) was accessed under ultrasound guidance, and a simultaneous arteriogram and venogram were done for localization. From the femoral access, an Outback Re-Entry Catheter (Cordis) was inserted to the level of the Tibio-Peroneal trunk, and a needle was advanced successfully into the PTV to create an arteriovenous fistula. Angioplasty for the track was done followed by covering it with a stent graft. Balloon Valvotomy was done up to the hind foot. The final angiogram showed a fast flow of contrast to the foot. The patient was discharged with improved clinical symptoms. The patient was reviewed in 3 months with a healed ulcer, no rest pain and a clinically patent arterialized PTV. Conclusion: In situ arterialization of the deep veins using Outback Re-Entry Catheter (Cordis) is a new modified technique for endovascular management of end-stage CLI. It is technically feasible with good early clinical outcome in our patient.



Publication History

Article published online:
11 May 2021

© 2018. The Arab Journal of Interventional Radiology. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

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