Bilateral percutaneous deep venous arterialization in an immunosuppressed lung transplant patient with no-option critical limb threatening ischemia

Patients with no-option critical limb threatening ischemia (CLTI) often require major amputations for source and/or pain control. Furthermore, their comorbidities can inhibit proper wound healing. Percutaneous deep venous arterialization (pDVA) has resulted in mixed, though mostly favorable outcomes, even in patients with multiple comorbid conditions. We present the case of a 58-year-old-male with a history of insulin-dependent type 2 diabetes mellitus (HbA1c 8.4%) and idiopathic pulmonary fibrosis, status-post lung transplantation, on immunosuppression who presented with bilateral Rutherford Class 5 CLTI. The patient was referred for bilateral below-knee amputations following multiple failed interventions. The patient elected to undergo left, followed by right lower extremity pDVA as a final attempt toward limb salvage. The LimFlow device was used for his left lower extremity as a participant of the PROMISE II trial and the right lower extremity pDVA was performed off-the-shelf. He subsequently underwent bilateral guillotine transmetatarsal (gTMA) amputations. The patient remains free from major amputation following initial pDVA at 25 months on the left and 14 months on the right. Following the initial pDVA, the patient required bilateral secondary interventions to maintain patency of the circuits and to alleviate ischemic steal. The left gTMA wound healed completely by secondary intention and the right gTMA wound had a skin substitute placed and is contracting with healthy granulation tissue. pDVA has evolved into a viable therapy for revascularization in patients with no option CLTI, even in the setting of multiple comorbid conditions and immunosuppression. While we have seen success in this patient population, further studies are necessary to identify those who are most likely to benefit from this procedure.