Pedal Bypass With Deep Venous Arterialization:

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1 Pedal Bypass With Deep Venous Arterialization: Long Term Result For Critical Limb Ischemia With Unreconstructable Distal Arteries Pramook Mutirangura Professor of Vascular Surgery Faculty of Medicine Siriraj Hospital Mahidol University Bangkok Thailand

2 No Disclosure

3 Critical limb ischemia

4 Unreconstructable distal artery Completely occluded & calcified pedal artery

5 Heavy calcification and severe stenosis of the pedal artery Calcified post. tibial a.

6 Conventional pedal artery bypass

7 Pedal bypass with deep venous arterialization (PBDVA) Principle of surgical technique Common femoral artery PTFE graft Common femoral vein Long saphenous vein proximal artery composite graft distal pedal vein

8 Critical limb ischemia Ankle pressure = 60 mmhg ABI = 0.4 Oxygen pressure = 16 mmhg

9 Preoperative assessment

10 Duplex ultrasonography: assessment of pedal vein 3 mm. posterior tibial vein

11 Duplex ultrasonography : proximal femoral artery

12 Pedal bypass with deep venous arterialization (PBDVA) Steps of the surgical procedure

13 PBDVA surgical technique The patient in supine position

14 PBDVA surgical technique Posterior tibial vein isolation

15 PBDVA surgical technique Proximal femoral artery isolation

16 PBDVA surgical technique Contralateral vein harvesting & graft tunnelling

17 PBDVA surgical technique Harvested long saphenous vein

18 PBDVA surgical technique Proximal vascular anastomosis

19 PBDVA surgical technique Anastomosis of composite graft

20 PBDVA surgical technique Composite graft

21 PBDVA surgical technique Blood flow through composite graft

22 PBDVA surgical technique Posterior tibial venotomy

23 PBDVA surgical technique Vascular dilator for destruction of valvular competency

24

25 PBDVA surgical technique Distal vascular anastomosis

26 PBDVA surgical technique Distal vascular anastomosis

27 PBDVA surgical technique Distal vascular anastomosis

28 PBDVA surgical technique Complete vascular anastomosis

29 VDO: intraoperative angiography

30 Intraoperative angiography

31 PBDVA surgical technique Closure of surgical wounds

32

33 Complete healing of ischemic ulcer Preoperative Postoperative

34 Preoperative Postoperative

35 Distal anastomosis (VDO) Preoperative CTA Postoperative CTA

36 Foot circulation Preoperative CTA Postoperative CTA

37 Transcutaneous oxygen pressure preoperative postoperative O 2 pressure = 16 mmhg O 2 pressure = 63 mmhg

38 Foot level <20 mmhg Poor healing mmhg Equivocal >40 mmhg Good healing

39 Postoperation 1 year Postoperation 5 years

40 Immediate postoperation Postoperation 5 years

41 Quality of life Postoperation : 1 year Postoperation : 5 year

42 Long term outcomes of PBDVA (n=40)

43 Hemodynamic changes in CLI treated by PBDVA

44 Postoperative duplex ultrasonography Immediate postoperation 5-year postoperation

45 Postoperative duplex ultrasonography Immediate postoperation 5-year postoperation

46

47

48 Lt. femoral artery PBDVA Lt. posterior tibial vein Preoperative Postoperative

49

50

51 PBDVA R. iliac a. R. posterior tibial v. Preoperative Postoperative 4 wks Postoperative 2 yrs

52 Long term outcome : good quality of life 6 year-follow-up

53 Conclusions PBDVA has been proved to enhance limb salvage in critical limb ischemia with unreconstructable distal artery. PBDVA could tremendously increase not only blood supply to the ischemic foot but also collateral circulation of the whole ischemic leg. This hemodynamic change could maintain healthy foot circulation and provide limb salvage in the long term followup.

54 1-4 December 2015 Bangkok, Thailand

55 Comparative study of venous arterialization and pedal bypass in a patient cohort with critical limb ischemia Pedal bypass (n = 19) Venous arterialization (n = 21) Early occlusion 23% 15% 1-year patency 75% 71% Limb salvage 47% 53% Equal limb salvage After pedal bypass surgery (good distal a.) After venous arterialization (poor distal a.) Schreve MA, et al., Annals of Vascular Surgery

56

57 Pedal Bypass With Deep Venous Arterialization: Long Term Result For Critical Limb Ischemia With Unreconstructable Distal Arteries Pramook Mutirangura Professor of Vascular Surgery Faculty of Medicine Siriraj Hospital Mahidol University Bangkok Thailand

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