Chronic limb-threatening ischaemia (CLTI) in cases where there are no further standard treatment options for limb salvage represents the most advanced stage of peripheral arterial disease. For these “no-option” CLTI patients, an experimental treatment of foot vein arterialisation (FVA) was first described in 1912, however, it was never widely adopted as outcomes varied significantly most likely due to the complexity of the surgical intervention and lack of standardisation. In recent years there have been significant developments in performing FVA fully percutaneously and standardising the procedure with the introduction of specific indications for patient selection, a dedicated set of devices and structured follow up. This case represents the first UK use of the dedicated LimFlow System as a standardised procedure to perform percutaneous deep vein arterialisation (pDVA) in a “no option” CLTI patient according to the latest treatment recommendations in the literature, with outcomes out to 18 months post-procedure. We present the case of a 78 year old male diabetic patient with a history of contralateral below knee amputation who presented with ischaemic rest pain and dry gangrene involving his left heel and first and second toes. Following review by the lower limb multi-disciplinary team at our institution, the patient was deemed to have no surgical or endovascular treatment options, apart from major amputation, as there was no suitable target for either angioplasty or bypass. He was therefore referred as a candidate for percutaneous deep vein arterialisation (pDVA) with the LimFlow System (LimFlow SA, France). After screening of the patient according to the indications for use, the pDVA procedure was successfully performed resulting in complete resolution of ischaemic rest pain immediately following the procedure, and adequate revascularisation of the foot. Following the index procedure, the subject went on to have minor amputation of the first, second and third toes 2 months post initial procedure with further secondary angioplasty procedures to optimise the flow throughout the arterialised circuit up to 4 months after the initial procedure. He underwent elective completion transmetatarsal amputation at 13 months post index procedure. The surgical wounds post minor amputation and the heel wound showed continued healing, especially after secondary optimisation of the pDVA outflow, with tissue epithelialisation by 6 months and complete healing by 18 months after the index procedure. This case report demonstrates the clinical outcomes of a technically-successful standardised pDVA procedure with the LimFlow system including both limb salvage and wound healing at 18 months. It also highlights the importance of close clinical and radiological surveillance post-index procedure and the requirement for re-interventions to optimise wound healing.

中文翻译：

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英国首例经皮深静脉动脉化 (pDVA) 使用 LimFlow 系统治疗“无选择”慢性肢体威胁缺血的早期和 18 个月临床结果

在没有进一步的保肢标准治疗方案的情况下，慢性肢体威胁缺血 (CLTI) 代表外周动脉疾病的最晚期阶段。对于这些“无选择”的 CLTI 患者，足静脉动脉化 (FVA) 的实验性治疗于 1912 年首次被描述，然而，由于手术干预的复杂性和缺乏治疗，结果差异很大，因此从未被广泛采用。标准化。近年来，通过引入特定的患者选择适应症、一套专用设备和结构化随访，在完全经皮执行 FVA 和标准化程序方面取得了重大进展。该病例代表英国首次使用专用 LimFlow 系统作为标准化程序，根据文献中的最新治疗建议对“无选择”CLTI 患者进行经皮深静脉动脉化 (pDVA)，结果可在术后 18 个月内完成-程序。我们介绍了一名 78 岁男性糖尿病患者，该患者有对侧膝下截肢史，表现为缺血性静息痛和干性坏疽，累及左脚跟和第一和第二脚趾。在我们机构的下肢多学科团队审查后，除了大截肢外，患者被认为没有手术或血管内治疗选择，因为没有合适的血管成形术或旁路手术目标。因此，他被认为是 LimFlow 系统（LimFlow SA，法国）经皮深静脉动脉化 (pDVA) 的候选人。根据使用适应症对患者进行筛查后，成功进行了 pDVA 手术，从而在手术后立即完全解决了缺血性静息痛，并对足部进行了充分的血运重建。在索引程序之后，受试者继续在初始程序后 2 个月对第一、第二和第三脚趾进行小截肢，并在初始程序后 4 个月内进行进一步的二次血管成形术以优化整个动脉化回路的流量。他在指数手术后 13 个月接受了选择性完成经跖骨截肢术。小截肢后的手术伤口和足跟伤口显示出持续愈合，特别是在 pDVA 流出的二次优化后，组织上皮形成 6 个月，并在指数手术后 18 个月完全愈合。本病例报告展示了使用 LimFlow 系统在技术上成功的标准化 pDVA 程序的临床结果，包括在 18 个月时进行肢体抢救和伤口愈合。它还强调了密切临床和放射学监测后指标程序的重要性以及重新干预以优化伤口愈合的要求。本病例报告展示了使用 LimFlow 系统在技术上成功的标准化 pDVA 程序的临床结果，包括在 18 个月时进行肢体抢救和伤口愈合。它还强调了密切临床和放射学监测后指标程序的重要性以及重新干预以优化伤口愈合的要求。本病例报告展示了使用 LimFlow 系统在技术上成功的标准化 pDVA 程序的临床结果，包括在 18 个月时进行肢体抢救和伤口愈合。它还强调了密切临床和放射学监测后指标程序的重要性以及重新干预以优化伤口愈合的要求。