Deep Vein Arterialization: Critical Limb Ischemia Diabetic Foot Ulcer Healed With Novel Skin Graft

L. Raja, A. Valles

Purpose: The rising number of diabetics has increased the demand for more advanced endovascular procedures and wound care modalities. Successful revascularization is the first step to optimal wound healing but unfortunately does not always provide sufficient blood flow. Patients with multiple comorbidities and end stage diseases often have restricted blood flow below the ankle to the arteries directly supplying oxygen to each individual ulcer for healing. Deep vein arterialization (DVA) is a technique used in limb salvage for patients left with no option except amputation. This case study exhibits the innovative procedure in a fifty-seven-year-old male with diabetes, renal disease, and a necrotizing foot ulcer.

Materials and Methods: IVUS of the left SFA, popliteal artery, TP trunk and posterior tibial vein. Subsequently, patient also underwent a re-entry to the posterior tibial vein with subsequent PTA to the left tibioperoneal trunk of the arterial system and PTA of the posterior tibial vein going all the way to the plantar vein and pedal venous, pedal loop PTA. PTA to the pedal loop and anterior tibial vein utilizing a Wolverine cutting balloon and followed by PTA using multiple balloons. The first was 2.0 then 3.0 followed by 4.0x 80 and at the end PTA the entire posterior tibial vein going into the TP trunk a 5.0 x 200 balloon. Next placement of a covered stent originating from the posterior tibial vein at the plantar area going all the way into the TP trunk 5.0 x 250 and 150 followed by post-dilatation.

Results: DVA was successful and supplied blood flow below the ankle into the pedal loop feeding the tissue at the ulcers. Studies show after revascularization wound healing is at 53% vs 20% without a successful intervention. The standard of care had been the treatment plan for wound care now with adequate blood flow and oxygen delivery to the tissue; advanced modalities were implemented. The patient’s own healthy skin was harvested to create a skin graft promoting new granulation and healing.

Conclusions: Limb preservation was possible with the DVA technique in endovascular interventions. Dermistat skin grafts, copper dressing and other novel wound care therapies are critical to the multidisciplinary approach to saving limbs and lives.