TADV - deep venous arterialisation for no hope CLTI. Talk by Miguel Monteiro-Baker

Combining two talks in this section.

Firstly, a descriptive talk on use of LIMFLOW to arterialise the pedal venous arch in CLTI patients with no conventional revascularisation options by Miguel Montero-Baker.

Latterly, a few slides from Steven Kum’s talk on the LIMFLOW device evolved technology.

PROMISE and ALPS are registries of deep venous arterialisation for CLTI. Miguel says PROMISE 2 is with the FDA at present. He emphasises that all patients in both registries were those with CLTI facing major amputation and highlights the 24 month 75% limb salvage rate in that context.

Miguel (and later Peter Schneider, during the discussion) emphasised a high MAC score (medial arterial calcification, as per Roberto Ferraresi’s work) to be instrumental in flagging up CLTI patients at high risk of being no-hopers for conventional revasc.

The AV fistula creation (percutaneously) needs the LIMFLOW device. A needle is pushed through from the artery (with IVUS guidance) into the vein, and retrieved to have a through and through wire. Valvulotomy, and covered stent.

There was a great deal of discussion about this approach. The two main issues are (a) getting the valves done and (b) actually perfusing into the tissue. Peter Schneider made some very useful comments. Apparently the foot looks dreadful for the first week. And it takes about 3 weeks for the wound to start showing any improvement - presumably because it takes that long for the effect of the AVF to start telling on the tissue. So Schneider emphasised that this isn’t a strategy appropriate for a large wound with rapidly progressing infection.