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Between a Rock and a Hard Place: A Case of Critical Limb Threatening Ischemia Treated with Deep Vein Arterialization
Carrie Tackett, Diego Monasterio, Rudy Sanchez, David Blitzer
Community Memorial Hosptial, Ventura, CA
Background: Chronic limb threatening ischemia (CLTI) with no options for revascularization are particularly challenging for vascular specialists. The patients often times present with comorbid diabetes, smoking, hypertension, and other risk factors for advanced peripheral vascular disease.
When imaging demonstrates no clear target for bypass or endovascular revascularization (i.e., “desert foot”), deep vein arterialization (DVA) is potentially an option for limb salvage. The role of DVA, however, has less clear for younger patients in the context of trauma. The following is a case report describing DVA in a healthy 28-year-old patient following iatrogenic popliteal artery dissection.
Methods: Patient AB is a 28-year-old healthy male with no past medical history. He is a competitive martial artist and occupationally works as a firefighter—where he ultimately tore his anterior cruciate ligament on the job. Immediately following his ACL repair, the patient reported moderate to severe pain in the affected leg that prevented consistent ambulation or dedicated rehabilitation. AB sought care from a multiple vascular specialists at outside facilities that discovered the popliteal artery dissection and consequently, the patient underwent several attempted endovascular revascularizations that were unsuccessful. Approximately nine months after this point he presented to the office with gangrene to the tip of his right great toe and significant rest pain. Toe pressures were zero in all digits. Due to his age and adequate greater saphenous vein, the patient was underwent open surgical exploration and revascularization. We determined to explore distal inframalleolar targets along with peroneal targets for arterial revascularization; however none of these were of adequate size or patency as a distal target. We therefore proceeded with open deep vein arterialization via bypass from the suprageniculate popliteal artery to the distal posterior tibial vein.
Results: AB recovered well in the hospital and was subsequently discharged home. Following open DVA, toe pressures improved from to 0 in all five digits to 20-30 mmHg. Six months post-operatively and AB has nearly healed from serial debridement of his great toe and has significant improvement in rest pain; though claudication persists.
Conclusions: The patient presented here is a young, healthy individual who sustained popliteal artery dissection and subsequent obliteration of his lower extremity outflow following ACL repair. He presented with CLTI following multiple unsuccessful revascularizations and therefore underwent open DVA. While the role of DVA has been described previously as a viable approach for no-option CLTI, its role with younger patients; particularly following traumatic or iatrogenic injury, is less well described. Our case suggests that DVA could improve limb salvage in this population and is a viable alternative to primary amputation for the right patient.
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