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Arterialization of the venous arch of the foot for the treatment of thromboangiitis obliterans

Abstracts

In critical ischemia without arterial run-off, it is possible to irrigate the ischemic limb by turning the course of the flow reversely through the venous system. The first experiments with therapeutic arteriovenous fistulas date from the beginning of the last century. They were performed in the proximal area of the lower limbs, but showed unfavorable results. Since the 1970's, with the pioneer studies of Lengua, fistulas started being extended to the foot and several publications have reported good outcomes. The authors report the evolution of a case of thromboangiitis obliterans which was submitted to the procedure. This is an accurate surgical procedure which requires arterial and venous preoperative study and the observance of technical operative details.

Venous arterialization; critical ischemia; therapeutic arteriovenous fistulas; limb salvage; thromboangiitis obliterans


Em isquemia crítica sem leito arterial distal, um dos modos de irrigar o membro isquêmico é derivar o fluxo de maneira retrógrada através do sistema venoso. As primeiras tentativas de fístulas arteriovenosas terapêuticas datam do início do século passado. Realizadas na parte proximal dos membros inferiores, não obtiveram resultados favoráveis. A partir da década de 70, com os trabalhos pioneiros de Lengua, as fístulas passaram a ser estendidas até o pé, e os bons resultados apareceram em várias publicações. Os autores relatam a evolução de um caso de tromboangeíte obliterante submetida ao procedimento. Essa é uma cirurgia de indicação precisa, que requer estudo pré-operatório arterial e venoso e observância a detalhes de técnica operatória.

Arterialização venosa; isquemia crítica; fístulas arteriovenosas terapêuticas; salvamento de membro; tromboangeíte obliterante


CASE REPORT

Arterialization of the venous arch of the foot for the treatment of thromboangiitis obliterans

Cesar Roberto BusatoI; Carlos Alberto Lima UtraboII; Ricardo Zanetti GomesII; Joel Kengi HousomeII; Eliziane HoeldtkeIII; Cristiano Teixeira PintoIV; Rafael Ignácio BrandãoIV; Cintia Doná BusatoV

IAssociate professor, Universidade Estadual de Ponta Grossa, Ponta Grossa, PR, Brazil. Member, SBACV

IIMember, SBACV

IIIVascular surgeon, Santa Casa de Misericórdia de Ponta Grossa, Ponta Grossa, PR, Brazil

IVResident, Vascular Surgery and Angiology Service, Santa Casa de Misericórdia de Ponta Grossa, Ponta Grossa, PR, Brazil

VMedical Student, Faculdade Evangélica de Medicina do Paraná, Curitiba, PR, Brazil

Correspondence

ABSTRACT

In critical ischemia without arterial run-off, it is possible to irrigate the ischemic limb by turning the course of the flow reversely through the venous system. The first experiments with therapeutic arteriovenous fistulas date from the beginning of the last century. They were performed in the proximal area of the lower limbs, but showed unfavorable results. Since the 1970's, with the pioneer studies of Lengua, fistulas started being extended to the foot and several publications have reported good outcomes. The authors report the evolution of a case of thromboangiitis obliterans which was submitted to the procedure. This is an accurate surgical procedure which requires arterial and venous preoperative study and the observance of technical operative details.

Keywords: Venous arterialization, critical ischemia, therapeutic arteriovenous fistulas, limb salvage, thromboangiitis obliterans.

Introduction

Attempts to bring arterial blood through retrograde venous approach to territories of large ischemia date from the early 20th century, performed by San Martin (1902). The observations by Gallois & Pinatelle (1903)that a much higher force than normal blood pressure is required to overcome venous valve obstacles also date from the same time. Helsted & Vaughan (1912) heavily criticized these procedures, although Roussiel, in 1919, showed success in 25% of 63 cases.1

In 1951, Szilagyi, a landmark of vascular surgery of that time, condemned this method after applying it in nine cases, which presented 100% of poor outcomes, creating arteriovenous fistulas in femoral vessels.2

Root & Cruz (1965) and Matolo (1976) experimentally showed that laterolateral fistulas allowed good venous reflux and better outcomes than terminolateral fistulas, whose venous overload led to edema, ecchymosis and necrosis.3,4

Avalos, in 1909, was the first to use the superficial venous system to create a fistula using the great saphenous vein communication with the femoral artery.1 Courbier, in 1973, and especially Lengua and his studies after 1974, started extending their fistulas until the foot, obtaining irrigation of toes and better outcomes than their predecessors.5

Venous grafts with reverse saphenous vein grafts deriving flow of the most distal artery and with good flow until the venous arch were successfully performed by Porkrowski, Lengua, Chen, Taylor, Engelke, Rowe and Özbek.6-17 The authors of this study, like Gasparis, maintain arterialized in situ great saphenous vein.18,19.

Good outcomes of this surgery are related to accurate indication, arterial and venous preoperative study of the limb at risk and details of the operative technique. The surgery has accurate indication for the treatment of critical ischemia without arterial run-off, with the aim of treating pain at rest or healing minor amputations.

Atherosclerosis obliterans, especially when associated with diabetes mellitus, thromboangiitis obliterans in most cases, and popliteal aneurysm with distal bed thrombosis are conditions in which critical ischemia without run-off is more frequent. Although thromboangiitis obliterans occurs both in veins and arteries, great and small arteries are rarely affected by the inflammatory process.20

Case report

A 52-year-old male patient, smoker, presented with pain at rest and cyanosis in the left foot 30 days ago. He reported dark spot in the digital pulp, in the right hand, for 60 days, which evolved with superficial necrosis and tissue desquamation. Physical examination showed palpable and full femoral and popliteal pulses; reduced right pedal pulse; absent posterior tibial and left pedal pulses. He progressed with necrosis of the hallux (Figure 1).


Duplex scan and arteriography of the left lower limb (Figure 2) showed preserved femoral and popliteal arteries, arterial circulation until the proximal third of the leg and absence of distal bed.


The patient was diagnosed with thromboangiitis obliterans and submitted to lumbar sympathectomy, and there was worsening of pain. Arterialization of the venous arch of the foot was performed. The great saphenous vein was maintained in situ, anastomosed at the popliteal artery (Figure 3) and skeletonized by ligation of collateral veins until the perforating vein of the malleolus (Figure 4), after which the foot veins were preserved. Valvulotomy along the saphenous vein was performed through the collateral veins, as well as in the venous arch of the foot close to the emergence of the first metatarsals (Mills valvulotome was used) (Figure 5). The hallux was then amputated for first intention healing.




The patient progressed with limb heating, improvement in pain, presence of pulse with thrill in the venous arch of the foot and healing of the hallux (Figures 6 to 8).


Discussion

Arteriography and arterial duplex scan are routinely performed to search for run-off for the treatment by conventional graft and better donating artery. Venous duplex evaluates and preferentially marks the great saphenous vein and its extension until the venous arch of the foot, as well as the other veins of the deep venous system, which ensure return of the flow generated by creation of the fistula.

The surgical technique can be performed as described by Lengua, who performs distal anastomosis with inverted saphenous vein directly in the venous arch or as suggested by the authors of this report: maintaining the great saphenous vein in situ12,18.

Sherman, in 1949,described eight perforating veins in the medial portion of the foot and seven in the lateral. Lofgren, in 1968, injecting latex in perforating veins of the dorsal arch between the first and the second metatarsal under pressure, observed the filling of the deep veins of the foot that, in turn, filled the superficial veins of the proximal portion. After dissecting 10 amputated limbs, the author found six to 12 perforating veins (nine in average), which communicated the deep with the superficial venous system. Of 94 dissected perforating veins, 49 had no valves, allowing venous flow in both directions, 41 had a valve close to the superficial system and four had a second valve.21

During phlebographic examinations, movements of dorsal and plantar flexion of the foot aspirate contrast for the deep circulation. In the foot, most perforating veins do not have a valve, and venous flow occurs in both directions. The most important perforating vein is in the first interdigital space, with approximately 3 mm.22 These findings can be confirmed by postoperative arteriography of the patient, which showed diffusion of the contrast in the dorsal and plantar venous archs.

A recent study analyzed 56 available studies in the international literature using arterialization of the venous arch of the foot for the treatment of critical ischemia without arterial run-off. Seven studies met the criteria of follow-up, patency time of the fistula and postoperative complications. A meta-analysis of these studies resulted in a total of 228 patients with 231 limbs and a salvage rate of 71%, with healing of scars, minor amputations and improvement in pain at rest. Of all cases, 140 were atherosclerosis and 91 were thromboangiitis obliterans.23

Although the international literature shows an increase in publications using this method, a substantial number of patients without distal run-off, especially with thromboangiitis obliterans, are still submitted to lumbar sympathectomy and progressive amputations of toe, metatarsus, foot and leg. The absence of new Brazilian studies on the arterialization of the venous arch of the foot shows that surgery is not practiced by Brazilian surgeons with the expected frequency.

References

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  • Correspondência:
    César Roberto Busato
    Rua Saldanha da Gama, 425
    CEP 84015-130 - Ponta Grossa, PR
    Tel.: (42) 3224.3288
    Email:
  • Publication Dates

    • Publication in this collection
      08 Dec 2008
    • Date of issue
      Sept 2008

    History

    • Received
      07 Nov 2007
    • Accepted
      17 July 2008
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