Venous arterialisation in advanced chronic lower limb ischaemia
When the arteries in the leg stop supplying enough blood to the foot, the tissue gradually begins to suffer. Initially, pain may occur when walking. Later on, pain may occur even at rest, along with wounds that do not heal or injuries that could jeopardise the preservation of the limb.
This is known as advanced chronic lower limb ischaemia, one of the most serious forms of peripheral arterial disease.
In certain patients, vascular deterioration reaches such a level that conventional revascularisation techniques are no longer sufficient. In this context, venous arterialisation represents an advanced therapeutic alternative aimed at restoring the supply of blood and oxygen to the tissue by using the venous system as a new route of perfusion.
What is chronic limb-threatening ischaemia?
Peripheral arterial disease occurs when the arteries carrying blood to the legs gradually narrow due to atherosclerosis, the same process that can affect the coronary or cerebral arteries.
Initially, the body manages to partially compensate for the reduced blood flow. This is why many people initially experience only pain or muscle fatigue when walking certain distances – symptoms known as intermittent claudication or, commonly, ‘window-shopping disease’. These symptoms are sometimes mistakenly attributed to ageing and/or joint problems.
But the vascular disease can continue to progress.
Over time, blood flow becomes insufficient even to meet the basic needs of tissue at rest. This is when persistent pain, a sensation of cold in the foot, skin changes and wounds that fail to heal properly begin to appear.
In advanced chronic ischaemia, the tissue no longer receives the oxygen it needs to remain viable. And that completely changes the prognosis.
This is because a small ulcer on a foot with preserved circulation can heal without too much difficulty. In contrast, the same lesion on a severely ischaemic foot can progress to deep infection, necrosis and irreversible tissue loss.
The leading international guidelines on vascular surgery now emphasise that this condition should not be understood solely as a problem of ‘poor circulation’. The actual severity also depends on the condition of the tissue, the presence of infection and the patient’s ability to heal. These recommendations were set out in the Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischaemia, published jointly by the European Journal of Vascular and Endovascular Surgery and the Journal of Vascular Surgery.
In this context, the Angiology and Vascular Surgery team at the Publio Cordón Memorial Hospital recently performed a deep venous arterialisation in a hybrid theatre on a patient with advanced chronic ischaemia and at risk of limb loss.
Dr Isaac Martínez López, head of Angiology and Vascular Surgery at the hospital and of the Diabetic Foot and Lower Limb Ischaemia Unit, explains that these patients often present with extremely complex vascular conditions, in which the problem no longer affects only the arteries, but also the tissue’s own ability to remain viable.
“The patient presented with critical ischaemia and a real risk of limb loss, with virtually no conventional revascularisation options available. When tissue ceases to receive sufficient blood supply, pain, non-healing wounds and a progressive risk of necrosis and infection begin to appear.”
What does it mean to have a ‘deserted foot’?
Many patients with advanced chronic ischaemia also have diabetes mellitus, kidney failure, heart disease or diffuse vascular disease. All of this greatly increases the clinical complexity.
In some cases, the smaller arteries in the leg and foot — those responsible for carrying blood to the distal tissue — may be completely calcified, obstructed or virtually non-functional.
Specialists refer to this condition as ‘desert foot’. The term describes a particularly complex scenario: a foot where there is no longer a functional distal arterial network capable of providing sufficient blood flow to the tissue.
Dr Isaac Martínez López explains that, in this type of patient, conventional procedures to improve circulation have often already been attempted without achieving sufficient results, precisely because of the extreme deterioration of the distal arteries.
For decades, when there was no suitable artery on which to perform a bypass or conventional angioplasty, treatment options were very limited and the risk of amputation increased considerably.
The role of the hybrid operating theatre in advanced vascular surgery
Technological advances have profoundly changed this landscape. The introduction of hybrid operating theatres makes it possible to combine advanced vascular surgery, endovascular techniques and real-time vascular radiological imaging within a single surgical environment.
At the Publio Cordón Memorial Hospital, this type of infrastructure enables highly complex vascular procedures to be undertaken using highly specialised therapeutic strategies.
Real-time intraoperative imaging allows surgeons to navigate the interior of arteries and veins barely a few millimetres in diameter, adapt the strategy during the procedure and access particularly complex anatomical regions.
The most recent international guidelines on peripheral arterial disease also emphasise the importance of revascularisation strategies — whether surgical, endovascular or hybrid — in an effort to prevent limb loss in patients with advanced chronic ischaemia. These recommendations are set out in the 2024 update from the American Heart Association (AHA) and the American College of Cardiology (ACC) on peripheral arterial disease.
Dr Mariano Palena, an interventional radiologist with extensive international experience in advanced limb-preserving techniques, points out that many of these patients have extremely advanced vascular disease, with heavily calcified arteries and distal vessels barely a few millimetres in diameter, which makes it essential to plan every step of the procedure carefully.
“We work on very small and severely diseased vessels, guided continuously by real-time vascular imaging. Precision is essential because we must navigate within severely damaged arteries and veins whilst striving to preserve as much viable tissue as possible.”
What is deep venous arterialisation?
Deep venous arterialisation is based on a complex physiological concept that is, however, relatively straightforward to understand. Normally, arteries carry oxygenated blood from the heart to the foot, whilst veins return blood back to the heart.
Dr Mariano Palena explains that the physiological aim of the procedure is to alter the usual path of blood flow in an attempt to restore oxygen and nutrients to areas where the arterial network is no longer functional.
“What we are aiming to do is redirect arterial blood into the distal venous system to try to restore perfusion to the tissue when the arteries in the foot are no longer functional. The aim is not merely to generate blood flow, but to ensure that the tissue once again receives sufficient oxygen to promote healing and reduce the risk of limb loss.”
Although the concept may seem counterintuitive at first, this technique involves a great deal of anatomical and haemodynamic complexity.
Venous arterialisation requires very precise patient selection, a thorough anatomical assessment and advanced expertise in endovascular surgery supported by highly complex vascular technology.
The aim is not merely to observe circulation on an angiogram. The real aim is to ensure that sufficient oxygen reaches the tissue in order to promote healing, alleviate ischaemic pain and reduce the risk of major amputation.
In recent years, various international scientific publications have reinforced interest in this strategy for patients considered ‘without options’, that is, those for whom conventional revascularisation techniques are no longer viable.
One of the most significant studies recently published in the New England Journal of Medicine evaluated transcatheter deep venous arterialisation in patients with chronic limb-threatening ischaemia for whom conventional treatment options were unavailable. The study demonstrated significant clinical outcomes in terms of limb preservation and amputation-free survival in patients who were extremely complex from a vascular perspective.
How venous arterialisation is performed in a hybrid theatre
The procedure is carried out using minimally invasive techniques.
Specialists access the interior of arteries and veins via small punctures and navigate using extremely fine devices guided by fluoroscopy, a real-time vascular radiological imaging technique that allows continuous visualisation of the path within the blood vessels.
The procedure is carried out entirely from within the blood vessels, avoiding conventional open surgery.
Dr Mariano Palena explains that the procedure is based on advanced endovascular navigation, continuously guided by real-time radiological imaging.
“It is a completely endovascular and minimally invasive procedure. We gain access via small punctures and advance very fine devices through the arteries and veins, guided continuously by fluoroscopy, which allows us to work with great precision within highly complex vessels.”
One of the most technically delicate moments occurs during the so-called ‘double loop’ manoeuvre.
On the angiography monitors, arteries and veins appear as structures measuring just a few millimetres, which must be aligned at an extremely precise anatomical point. Under angiographic guidance, both vascular systems must be brought together with millimetre precision to enable the safe creation of the connection between the artery and the vein. Small intravascular loops are positioned within both vessels to serve as navigation markers.
At this point, a microneedle is carefully passed from the arterial system into the venous system, passing exactly through the centre of both loops.
An extremely fine guidewire is inserted through this needle and is subsequently retrieved from the venous system, creating a continuous and stable pathway within the body along which angioplasty balloons and drug-eluting stents can subsequently be advanced.
Subsequently, the venous valves — whose usual function is to prevent blood from flowing back towards the foot — must be carefully modified to allow for the new direction of blood flow.
Finally, using coated stents, arterial blood can be directed into the distal venous system in an attempt to restore blood supply to tissues that had previously been virtually isolated from the circulatory system.
What results can be expected
Deep venous arterialisation is currently one of the most complex and specialised treatment options available for patients with advanced chronic ischaemia who have no conventional treatment options.
However, not all patients are suitable candidates, and it is not always possible to avoid amputation.
Outcomes depend on multiple factors:
The severity of the vascular disease.
Presence of infection.
Tissue condition.
The patient’s metabolic status.
Healing capacity.
Following the procedure, Dr Isaac Martínez López points out that the patient’s progress must be assessed progressively over the following days and weeks, as the venous system needs to adapt to this new circulatory dynamic.
“Following the procedure, we already observe an initial improvement in foot perfusion, although these procedures require time to fully assess the clinical outcome. The aim is to ensure that the tissue gradually begins to receive sufficient oxygen again to promote healing and reduce the risk of amputation.”
Venous arterialisation is not a substitute for conventional revascularisation techniques and should be reserved for carefully selected patients treated at centres with advanced expertise in vascular surgery and complex endovascular therapies.
However, in certain cases of advanced chronic ischaemia where no conventional alternatives are available, it may represent a therapeutic option aimed at preserving the limb and improving the patient’s quality of life.
Frequently asked questions about deep venous arterialisation
When is deep venous arterialisation considered?
It is usually considered for patients with advanced chronic ischaemia in whom the arteries of the foot are so severely damaged that conventional bypass or angioplasty techniques are no longer viable.
What is the difference between conventional angioplasty and deep venous arterialisation?
Conventional angioplasty aims to reopen diseased arteries to restore normal blood flow. In deep venous arterialisation, when these arteries are no longer functional, the deep venous system is used as an alternative route to try to restore the flow of oxygenated blood to the foot.
Does venous arterialisation replace surgical bypass?
No. Bypass surgery and conventional revascularisation techniques remain the first choice where the anatomy is suitable. Deep venous arterialisation is usually reserved for particularly complex patients for whom there are no effective conventional alternatives.
How long does it take to see an improvement following the procedure?
Clinical improvement is not always immediate. The venous system needs to adapt gradually to the new blood flow, and recovery depends on the patient’s pre-existing tissue condition, any infection, diabetes and individual healing capacity.
Why do these procedures require specialised hybrid theatres?
Because they combine advanced endovascular navigation, real-time vascular imaging and high-precision technology within technically very complex procedures performed on small-calibre vessels and severely diseased anatomy.
Can all patients with diabetic foot benefit from this technique?
No. The indication depends on multiple clinical and anatomical factors. Each case must be assessed individually by teams specialising in vascular surgery, diabetic foot and advanced endovascular therapies.
This content is for information and educational purposes only and is not a substitute for an individual medical assessment.
The information in this article is provided for general awareness and does not replace an individualised medical assessment.
