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Corresponding author. Vascular and Endovascular Unit, Department of Surgery, Pederzoli Hospital, 26 Via Monte Baldo, 37019, Peschiera del Garda, VR, Italy.
Deep foot vein arterialisation is an alternative in patients with “no option” critical limb ischaemia, especially when performed with a total percutaneous approach.
Technique
With antegrade access from the ipsilateral common femoral artery, using a 6 F sheath (10 cm), digital subtraction angiography is performed to locate the best tibial artery to create the arteriovenous fistula (AVF) according to ischaemic lesion location and venosome.
The tibial artery is navigated as far distally as possible and percutaneous transluminal angioplasty is performed with a 3 mm balloon; this is to try to create the AVF in the most distal tibial vessel.
The Pioneer Plus catheter (Philips Volcano) is then used to create the AVF.
With intravascular ultrasound (IVUS) image guidance, the best zone in which to create the AVF is located, where the artery is less calcified and the vein has an adequate diameter. The IVUS catheter also allows evaluation of the correct distance between the artery and vein and also how many mm the needle is required to be pushed out.
A puncture from the artery into the vein with the Pioneer Plus (Fig. 1) is made, and when the 0.014 guidewire is in the vein a covered stent (Begraft coronary; Bentley Innomed GmbH) 3.5 or 4 mm in diameter and 24 mm in length is placed, and the distal portion is flared into the vein to make the AVF.
Figure 1Arteriovenous fistula (AVF) creation at tibial level. (A) Intravascular ultrasound image, the posterior tibial artery and vein can be seen (at 12 o'clock), and the distance between the artery and vein can be evaluated. (B) Fluoroscopic image, during AVF creation, with a 0.014 guidewire in the vein. (C) Begraft coronary covered stent across artery and vein. (D) The Pioneer Plus device from Philips Volcano.
The procedure is completed by performing valvulotomy of the tibial and foot veins using 5 mm balloon inflation or a 4 F over-the-wire valvulotome (Andravalvulotome; Andramed GmbH), providing effective valvulotomy in most patients, although the valvulotome is not for antegrade use. The final result is shown in Fig. 2.
Figure 2Final angiogram. (A) Arteriovenous fistula (AVF) at the middle third of the posterior tibial vessels. (B) Antero–posterior view of arterialised foot veins. (C) Lateral view of arterialised foot veins.
Since May 2017, seven patients have been treated with a 100% procedural success. During follow up (207 ± 76days), there have been two complete wound healings, four wound improvements and one major amputation.
Conclusion
Initial experience suggests that use of the Pioneer Plus to create an AVF is effective and easy.
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