Transcatheter Arterialization of Deep Veins in Chronic Limb-Threatening Ischemia

N Engl J Med. 2023 Mar 30;388(13):1171-1180. doi: 10.1056/NEJMoa2212754.


Background: Approximately 20% of patients with chronic limb-threatening ischemia have no revascularization options, leading to above-ankle amputation. Transcatheter arterialization of the deep veins is a percutaneous approach that creates an artery-to-vein connection for delivery of oxygenated blood by means of the venous system to the ischemic foot to prevent amputation.

Methods: We conducted a prospective, single-group, multicenter study to evaluate the effect of transcatheter arterialization of the deep veins in patients with nonhealing ulcers and no surgical or endovascular revascularization treatment options. The composite primary end point was amputation-free survival (defined as freedom from above-ankle amputation or death from any cause) at 6 months, as compared with a performance goal of 54%. Secondary end points included limb salvage, wound healing, and technical success of the procedure.

Results: We enrolled 105 patients who had chronic limb-threatening ischemia and were of a median age of 70 years (interquartile range, 38 to 89). Of the patients enrolled, 33 (31.4%) were women and 45 (42.8%) were Black, Hispanic, or Latino. Transcatheter arterialization of the deep veins was performed successfully in 104 patients (99.0%). At 6 months, 66.1% of the patients had amputation-free survival. According to Bayesian analysis, the posterior probability that amputation-free survival at 6 months exceeded a performance goal of 54% was 0.993, which exceeded the prespecified threshold of 0.977. Limb salvage (avoidance of above-ankle amputation) was attained in 67 patients (76.0% by Kaplan-Meier analysis). Wounds were completely healed in 16 of 63 patients (25%) and were in the process of healing in 32 of 63 patients (51%). No unanticipated device-related adverse events were reported.

Conclusions: We found that transcatheter arterialization of the deep veins was safe and could be performed successfully in patients with chronic limb-threatening ischemia and no conventional surgical or endovascular revascularization treatment options. (Funded by LimFlow; PROMISE II study number, NCT03970538.).

Publication types

  • Multicenter Study

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Amputation, Surgical* / methods
  • Amputation, Surgical* / mortality
  • Arteries / surgery
  • Arteriovenous Shunt, Surgical* / methods
  • Bayes Theorem
  • Catheterization
  • Chronic Limb-Threatening Ischemia* / mortality
  • Chronic Limb-Threatening Ischemia* / surgery
  • Endovascular Procedures* / methods
  • Endovascular Procedures* / mortality
  • Female
  • Humans
  • Ischemia / mortality
  • Ischemia / surgery
  • Leg / blood supply
  • Leg / surgery
  • Leg Ulcer / physiopathology
  • Leg Ulcer / surgery
  • Leg Ulcer / therapy
  • Limb Salvage / methods
  • Limb Salvage / mortality
  • Male
  • Middle Aged
  • Peripheral Arterial Disease / mortality
  • Peripheral Arterial Disease / surgery
  • Prospective Studies
  • Risk Factors
  • Treatment Outcome
  • Veins / surgery
  • Wound Healing

Associated data