DVA: Updated Evidence, Techniques, and Management Post-Intervention

Deep vein arterialization (DVA) is an evolving revascularization strategy that offers an option for those who classically are considered as no-option critical limb threatening ischemia (CLTI) patients. This patient population, many who may have had multiple revascularization attempts, or sometimes none, face dangerously high rates of amputation and mortality that has been well described in the literature. These patients suffer from small vessel disease and anatomically demonstrate no suitable vessels for endovascular or surgical revascularization ("desert foot"). DVA creation involves a tibial artery-to-vein fistulization, and after additional interventions, enables retrograde delivery of oxygenated blood down the tibial vein towards the pedal venous arch. This article describes the indications and contraindications, pre-operative evaluation, various approaches to arterialization, and postprocedural DVA management. DVA creation can be a technically challenging procedure, particularly in patients with significant arterial inflow disease burden, difficult-to-navigate venous loops, and those with variable venous anatomy. Post-DVA reintervention is quite common, spanning from management of graft occlusion/stenosis, poor maturation, arterial steal, and venous hypertension. Furthermore, these patients require close clinical follow-up involving regular ultrasound surveillance and close collaboration with foot and ankle surgeons for amputation strategy planning. Lastly, there is a continually growing body of evidence demonstrating the efficacy of DVA as well as the benefits of early reintervention; overall, promising results for patients with no-option CLTI.