Deep veins arterialization: a limb salvage alternative? The P.I.S.A. technique (Peripheral intravascular and surgical vein arterialization)

AIM: In the absence of any possible surgical/endovascular revascularization of dorsal and plantar arterial circulation, three patients underwent surgical arterialization of lower limb deep veins as extreme limb salvage attempt. Short and middle term results were evaluated. METHOD: Throughout 2016 three diabetic patients (four limbs) underwent failed revascularization of lower limb, due to complete occlusion of foot arterial circulation, both on plantar and dorsal side. Each patient belonged to class 5 of Rutherford classification and required a major amputation. Vascular tree of these patients was characterized by massive calcifications due to chronic metabolic disease (diabetes and chronic kidney disease) and chronic corticosteroid therapy (heart transplant and polymyalgia). As extreme limb salvage attempt, we proposed to create a surgical popliteal artery-posterior tibial vein arterovenous fistula by using great saphenous vein as conduit and to “arterialize” posterior tibial vein and distal deep veins through endovascular techniques. RESULTS / DISCUSSIONS: Technical success was obtained in each case. In two cases arterialization of deep veins was incomplete due to concomitant plantar vein thrombosis. The postoperative stay was complications free. At 1 month follow up the two patients with plantar vein thrombosis required major amputation, despite peripheral gangrene demarcation has occurred. In two patients lower limb was saved. CONCLUSIONS: From our preliminary experience, an attempt of deep veins arterialization could represent an alternative option to major amputation in patients affected by critical limb ischemia at “terminal stage”. Outstanding problems are how to solve venous valves stenosis, timing and ways for eventual conservative foot amputations.