Fenestrated Transcatheter Arterialization of the Deep Veins: Protecting the Peroneal While Covering the Tibioperoneal Trunk.

OBJECTIVE: We describe a novel approach to transcatheter arterialization of the deep veins (TADV) in a patient with chronic limb-threatening ischemia using the LimFlow kit and a Culotte 2-stent bifurcation technique to maintain peroneal flow while deploying a covered stent graft into the tibioperoneal trunk and posterior tibial vein when there is no tibial artery suitable for the TADV inflow. KEY STEPS: (1) Antegrade access of the superficial femoral artery and ipsilateral lateral plantar vein, (2) crossover wire from the artery into the vein, (3) place the LimFlow stent graft connecting the artery to the vein, (4) fenestrate the stent graft to allow bifurcation stenting into the peroneal artery to preserve native peroneal flow, and (5) optimize the inflow and outflow from the graft.

POTENTIAL PITFALLS: Plantar venous access, compromising native arterial flow, and graft inflow/outflow issues require careful consideration during and after the TADV procedure.

TAKE-HOME MESSAGE: Alternative inflow TADV is feasible to maintain native arterial perfusion while the TADV circuit matures.