A new modified Surgical Technique of In Situ Reverse Arterialization: Leaving the Distal Saphenous Side Branches Open of Non-Reconstractable Ischemic Leg Leads to Full Recovery

Abstract Objective Arterializations of the feet veins in patients with ischemic feet usually results in excessive foot edema, wound infection, venous gangrene, long hospitalization duration and a high rate of amputation. Design We herein present an improved method of foot revascularization via the superficial venous system by In Situ Reverse Arterialization (ISRA) of the foot venous bed, leaving the distal saphenous side branches open. Methods A 69 year old patient with toe wet gangrene and end stage peripheral vascular disease, with absence of foot target arteries underwent ISRA procedure, using the Great Saphenous vein, which was anastomosed end to side to the proximal Superficial Femoral artery. Only proximal saphenous tributaries were ligated until arterial flow reached the pedal superficial veins. Results Post operatively, the foot regained normal pulsation over the superficial venous system. The patient did not experience foot edema. On-table subtraction angiography demonstrated arterial flow through the long saphenous and dorsal foot veins, with returned venous flow through the anterior and posterior tibial veins. Mibi scan conducted 4 weeks post-operatively, demonstrated positive oxygen uptake of the pedal muscles, which was absent before surgery. Electron microscopy of the muscles at the level of the trans metatarsal amputation demonstrated regeneration of muscle tissue with mitosis 6 weeks post-operatively. During 1000 days of follow up post-surgery the flow was reduced and the TcpO2 level of the foot increased up to 76mmHg. Conclusions This new modified surgical technique of ISRA, in which only proximal Saphenous tributaries were ligated in order to prevent high systemic pressure in the foot venous low pressure system, resulted in increased levels of TcpO2 and reduced flow, leading to full recovery of the ischemic foot.