Anterior tibial artery to anterior tibial vein deep venous arterialization in a chronic limb-threatening ischemia patient with long-term limb preservation

Dear Editor,

Deep venous arterialization (DVA) is increasingly utilized globally for patients with chronic limb-threatening ischemia (CLTI) without alternative revascularization options.^[1] A major challenge is small artery disease pattern or “desert foot,” where poor tibiopedal outflow precludes arterial revascularization. Prospective DVA trials (Promise I/II) report approximately 70% amputation-free survival (AFS) at 1 year.^[2,3] However, outcomes are worse in end-stage renal disease (ESRD), with only 36.8% AFS at 6 months in Promise II.^[3]

Most reported DVAs utilize the posterior tibial artery/posterior tibial vein (PTA/PTV) due to its favorable access and anatomy.^[1] Alternative conduits include the peroneal or tibioperoneal trunk. The anterior tibial artery/anterior tibial vein (ATA/ATV) conduit is less commonly utilized due to its superficial course and variable outflow anatomy. Nonetheless, ATA/ATV may be a viable option when other conduits are unsuitable.

To our knowledge, long-term limb salvage with ATA/ATV DVA has not been previously reported. This case describes a DVA with an ATA/ATV conduit in a 65-year-old man with diabetes and ESRD presenting with rest pain and a non-healing hallux amputation site. He had undergone multiple prior complex tibiopedal revascularizations by experienced operators, including direct tibial and plantar artery accesses, but his symptoms progressed. Given his desert foot pattern, DVA was pursued [Figure 1]. Initial PTA/PTV access was abandoned after the discovery of chronic PTV occlusion, prompting an ATA/ATV approach.

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Figure 1: 65-year-old man with diabetes and end-stage renal disease who presented with rest pain and a non-healing hallux, amputation site. (a) Ulcerated hallux wound before amputation. (b) Several weeks post-hallux amputation, with non-healing amputation site. (c) Diagnostic angiogram demonstrating a small artery disease vascular pattern, mostly through corkscrew-shaped collaterals, consistent with a “desert foot” appearance.

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Following antegrade common femoral artery access, the calcified proximal ATA was treated with rotational atherectomy and angioplasty to facilitate subsequent reentry needle crossing. A Pioneer (Philips, USA) reentry device was then positioned in the proximal ATA. From retrograde ATV access at the ankle [Figure 2], a semi-compliant balloon was advanced to the same level. Once parallel, the reentry needle punctured into the balloon, allowing antegrade arterial wire externalization through the venous access. Following serial venoplasty with high-pressure balloons up to 5 mm diameter [Figure 3a], self-expanding covered stents were deployed from just above the ankle joint in the ATV into the proximal ATA beyond the crossover site [Figure 3b]. Initial flow was sluggish due to a persistent venous valve near the ankle, so subsequently treated with a push surgical valvulotome and covered stent extension. Completion angiogram demonstrated widely patent flow into the midfoot venous loop [Figure 3c].

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Figure 2: 65-year-old man with diabetes and end-stage renal disease who presented with rest pain and a non-healing hallux amputation site. Fluoroscopic images demonstrating midfoot venous anatomy. (a) Venogram demonstrating outflow of theanterior tibial vein (black arrow) before deep venous arterialization creation. (b) Wire access into the anterior tibial vein (black arrow).

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Figure 3: 65-year-old man with diabetes and end-stage renal disease who presented with rest pain and a non-healing hallux amputation site. Creation of the arteriovenous connection. (a) Fluoroscopic image showing balloon angioplasty of the arteriovenous crossover point (black arrow). (b) Proximal inflow of the DVA, with black arrow demonstrating transition from artery to vein. (c) Immediate post-DVA angiogram demonstrating widely patent flow through arterialized plantar veins. DVA: Deep venous arterialization.

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The patient was managed with dual antiplatelet therapy and wound care. At early follow-up, rest pain resolved and the wound fully healed [Figure 4a-b]. An angiogram 3-year post-DVA (performed for the contralateral extremity) showed DVA occlusion but maintained perfusion through collateralization [Figure 4c]. This is consistent with the trend that early DVA patency (at least 6–8 weeks) may promote wound healing regardless of later occlusio. Remarkably, at 5-year follow-up, the patient remains symptom-free without reintervention.

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Figure 4: 65-year-old man with diabetes and end-stage renal disease who presented with rest pain and a non-healing hallux amputation site, now status-post anterior tibial artery/vein DVA creation. (a and b) Healed amputation site 5 years after DVA remains stable without reintervention. (c) Three-year post-DVA angiogram demonstrating persistent forefoot perfusion, increased compared to prior. DVA: Deep venous arterialization.

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This case demonstrates successful limb preservation utilizing a rare DVA approach with an ATA/ATV conduit. Furthermore, this case is notable for its long-term clinical success, evidenced by AFS and freedom from rest pain at 5 years without reintervention, despite failing all prior revascularization attempts. In conclusion, DVA can be an effective and durable option in CLTI patients without alternative revascularization options, even those without adequate posterior venous circulation.