The Massachusetts General Hospital Approach to Transcatheter Arterialization of the Deep Veins for Advanced Limb Salvage : Protocols and Procedures

This book presents an in-depth guide to transcatheter arterialization of the deep veins (TADV). TADV or deep venous arterialization (DVA) is an emerging technological and clinical solution for patients with peripheral artery disease who have no options for limb salvage based on conventional vascular techniques. It serves to salvage limbs in patients who would otherwise be amputated. For TADV to be successful in preventing amputation patient selection, pre-procedure imaging, technical expertise, and post-operative wound management must be optimized. The book takes a step-by-step approach to TADV to guide the clinical team through the patient journey from meeting a potential candidate for TADV through to saving the leg. Chapters provide a reference for patient selection, procedural steps, and post-operative wound care management. This is an ideal guide for vascular surgeons, interventional radiologists, interventional cardiologists, trainees, and all medical professionals caring for patients with severe peripheral artery disease potentially facing amputation. Contents Editors and Contributors About the Editors Contributors Part I: Patient Identification 1: Selecting the Correct Patient Candidate 1.1 Profile of a TADV Patient 1.2 Major Considerations 2: Evaluating the Angiogram 2.1 Stoplight Approach to Angiographic Screening 2.2 Tibial Donor Vessel Evaluation 3: Preprocedural Wound Considerations 3.1 How to Identify Appropriate Wounds SVS Wound (W) Category Wound Grade 1, An Appropriate Candidate (Fig. 3.1) Wound Grade 2, Additional Considerations Required (Fig. 3.2) Wound Grade 3, Additional Considerations Required (Fig. 3.3) SVS Foot Infection (fI) Category Foot Infection Grade 0, An Appropriate Candidate (Fig. 3.4) Foot Infection Grade 1, An Appropriate Candidate (Fig. 3.5) Foot Infection Grade 2, Additional Considerations Required (Fig. 3.6) Foot Infection Grade 3, TADV Not Advisable (Fig. 3.7) 3.2 Stop Light Approach to Wound Screening, WIfI 3.3 Stop Light Approach to Wound Screening, Location (Fig. 3.11) 3.4 Pre-TADV Wound Stability Scenario #1 Scenario #2 Scenario #3 4: Explaining TADV to the Patient and Family Part II: Patient Preparation 5: Duplex Pedal Mapping for Case Preparation 5.1 Introduction Purpose Indications and Limitations Equipment Patient Prep Procedure 5.2 Required Documentation Venous Arterial Mapping 5.3 Interpretation Venous 6: Preoperative Optimization of the Patient 6.1 History 6.2 Physical Examination 6.3 Optimizing Medical Conditions 6.4 Investigations 6.5 Antithrombotic Therapy Part III: Procedure and Acute Post- operative Care 7: Overview of TADV and Required Equipment 7.1 Anatomical Considerations 7.2 Equipment 8: Pedal Venous Access 8.1 Required Knowledge Base 8.2 Preoperative Pedal Venous Ultrasound 8.3 Recommended Products 9: Procedural Steps 9.1 Case Preparation 9.2 Pedal Access and Interventional Techniques (Fig. 9.2) 9.3 Venous Access Watch Outs and Tips 9.4 Femoral Access 9.5 Crossing Preparation 9.6 Artery to Vein Alignment: C-Arm Positioning Primary Alignment Method: Eclipse View and 90° Offset Secondary Alignment Method: Maximum Distance After Confirming the Correct C-Arm Position Crossing Needle Deployment: With the Arterial Catheter (ARC) Aligned to the Target Vein Artery to Vein Crossing: Advance Crossing Guidewire (Fig. 9.16) Artery to Vein Crossing: Guidewire Capture (Fig. 9.17) Artery to Vein Crossing: Guidewire Externalization Dilating the Conduit (Fig. 9.18) 9.7 Crossing Watch Outs and Tips 9.8 Valve Effacement 9.9 Stent Deployment (Fig. 9.20) Pedal Loop Wiring End of Case 10: Immediate Postoperative Care 10.1 Expectations After TADV 10.2 Post-Procedure Care 10.3 Wound Care 11: Post-TADV Care Plan Part IV: Post-procedure Care and Maintenance 12: Imaging the TADV Circuit 12.1 Duplex Ultrasound Surveillance 12.2 Limitations 12.3 Equipment 12.4 Patient Prep 12.5 Procedure 12.6 Required Documentation 12.7 Volume Flow Rate Considerations (Fig. 12.1) 12.8 Interpretation 13: Circuit Maintenance and Optimization 13.1 Indications for Intervention Post-TADV 13.2 Flow Optimization Nutritive vs Non-nutritive Flow in the Foot Non-nutritive Flow Imaging Characteristics 13.3 Symptoms of Non-nutritive Flow Clinical Signs of TADV Circuit Compromise 13.4 Flow Management Post-TADV 13.5 Flow Management Timing Key Indications for Intervention Changes in Blood Flow Characteristics and TADV Maturation Are Rapid in the Initial Weeks after TADV Timing 13.6 Volume Flow Interpretation 14: Wound Care 14.1 Day 0–90 Post-TADV 14.2 Treatment Plan Strategy for Infected Wounds 15: TADV and Beyond: Postoperative Care of the Patient with Forefoot Amputation Variations on Final TADV Imaging References Index