Hybrid superficial venous arterialization and endovascular deep venous arterialization

We report on two venous arterialization (VA) techniques for treatment of CLTI in patients traditionally considered as having no treatment options for standard arterial endovascular or surgical bypass procedures. Screening and the preprocedural workup findings are outlined as deciding factors in determining a patient’s fitness for the two techniques, with a focus on careful preprocedure arterial duplex ultrasound and assessment for vein suitability. Cardiac and infection screening are also factors in determining patient suitability for VA. In addition, radiographic assessment for the presence of medial artery calcification, which is used as a marker of technical difficulty and is a predictor of poor outcomes, is required. Ultimately, anatomic factors are used to determine the decision between hybrid superficial VA and or endovascular deep VA. Those with an occluded anterior tibial artery and suitable great saphenous vein are prioritized to hybrid superficial VA, and those with an occluded posterior tibial artery to endovascular deep VA. Both procedures are described in detail in this report of vascular and surgical techniques

The "Woundosome" Concept and Its Impact on Procedural Outcomes in Patients With Chronic Limb-Threatening Ischemia

This editorial assembles endovascular specialists from diverse clinical backgrounds and nationalities with a global call to address key challenges to enhance revascularization in chronic limb-threatening ischemia (CLTI) patients.- Dedicated below-the-ankle (BTA) angiography and revascularization is underutilized in ischemic foot treatment. Existing guidelines do not address comprehensive BTA vessel analysis. CLTI trials also often lack data on in-line arterial flow to the ischemic lesion and BTA vessel evaluation, hindering outcome assessment.- Dedicated multi-planar angiographic evaluation of the distal microcirculation is key: Direct arterial flow or good-quality collaterals are crucial in influencing wound healing and need to be assessed diligently to the level of the distal ischemic wound territory, termed “woundosome.”- An important primary emphasis of future trials should be on validating technologies and strategies for assessing tissue perfusion before, during, and after revascularization undertaken to heal tissue loss in CLTI patients. This will allow determination of a potentially significant delta in tissue perfusion prior to and following intervention at the “woundosome” level. Once changes in arterial perfusion have been identified as positively correlated to wound healing, these could serve as a much-needed novel primary technical outcome measure for patients with tissue loss undergoing surgical, hybrid, or endovascular revascularization