So, I'm going to present a case of a 61-year-old male. This is more or less like a gift that keeps on giving, so diabetes for more than 20 years, hypertension, epilepsy, anemia, presents with CLTF, which is not uncommon for a lot of our patients. This is his first presentation ever for PAD. Fontaine, 4, Rutherford, 5, WIFI, SPS, 1, 3, 1, which means about a 50 percent chance of getting amputated within a year without revascularization, TcpO2 of 2, Dorseman of 4, and Medio, 21. And this is his foot day 11. So we all know exactly what's going to be happening here unless we do something about this patient. So we did a diagnostic angiogram. You can see here aortic iliac overall looks okay. If you look on the right, the CFA looks good, profundus open, the proximal part of the SFA is open. And if you look in the very last picture on the right, you can see that there was reconstitution of popliteal. If you look here, the popliteal looks okay. If you look at the image in the middle, there's basically a complete meltdown of the infrapopliteal vessels. And when you make it down to the foot, we just see a bunch of arteries here, but really no name vessel to the foot. So you know this patient is in trouble. And so I have still images here. So SFA is occluded. You see reconstitution. And below the knee, all three are occluded. And we thought TPT was gone with peroneal and PT, but actually we found out later the patient did not have a PT. The patient had one of those anomalous peroneal that has become the posterior tibia at the foot level. So our revasculation strategy was to bring the patient. We're going to address the above knee first and then deal with the below knee afterwards. So our access is going to be integrate, right CFA, retrograde pop, or distal SFA, and try to make something happen, and then go from there. So this was the arrangement. You can see the integrate access and the right CFA and the retrograde in the popliteal. The patient was still in a prone position. And this is what happened after we got access. We struggled quite a bit. And so talking about retrograde and integrate, that's what we did here. But despite that, it was extremely difficult. So we did reverse CART. It didn't work. We did CART. Eventually, that ended up working. But we had to use, in a start of 42 cross, eventually use the ONA command to externalize. And the very last video, we have a retrograde for French Berenstain and an integrate NAVICross and be able to externalize the ONA command. After that, we use IVUS, as you can see here, the amount of calcium. So even the proximal SFA that's open, you can see calcium almost 360. And when we cross, there's some component of subentimal, but you can see the deep calcium here. So because of the fear that the outflow was poor, we put a filter, which it was a NAV6 because they have a free-floating wire over a VIPER wire. We used laser abstractomy just because of the amount of calcium that we had here. We did serodilatation. We used a 5, a 6, and ultimately a 7 balloon. And we see the yellow little mark is where there was still an arc of calcium there. And ultimately, we end up using a 7 Dorado balloon to really prep this vessel. So I use a 6.5 SEPER in the distal segment. And at the top, we use a 7 Alluvia to treat the proximal part. And down below in the distal SFA and popliteal, based on IVUS image, we use a 7-millimeter Ranger DCB. So this was our final result. There's a gradient in the proximal part. I'm sorry. There's two lesions there, but no gradient. SFA looks okay. But as you can see down below, there's absolutely nothing. We just see all these collaterals, but really no direct vessel that we can reconnect to. So this is what it looks like by angiography. And so our plan was let's monitor the patient, let's see what we can do. Obviously, the wound did not get better. And we can see our TCPO2 improved some within two months, but still below the healing threshold. And we did check the numbers as well with hyperbaric. So question was, what do we do next? So we decided we're going to look at this approach of deep venous arterialization for no option CLTI patient, multiple fetal intervention, or for people that have poor outflow due to sad disease, like which is the case for this guy, or recurrent tibial restenosis, extremely calcified vessel, or patients that have unreconstructable vessel, either because they're too calcified or they're completely obliterated, or patients without targets or conduit. But still, they have to have a viable foot, which we can see in approximately about 20% of our CLTI patient. So the idea is normally you have arteries making it to the capillary, delivering blood. You have vein taking blood back to the heart. In this case, those arteries don't exist, and we'll make a conduit connecting the remaining artery to a vein. We take one vein that we confuse to deliver oxygen and blood to the foot. So you can do it percutaneously, surgically, or hybrid. And the concept is to pressurize the vein, backfill the capillaries, improve tissue perfusion, and ultimately trigger angiogenesis, and hopefully help to save the foot. So we bring the patient back. This was going to be our target. So that's where the artery should be, but it's not there. And this is where the vein should be. And we decided we're going to make a conduit right there. And the idea was to get this conduit all the way down to the foot and give blood to the foot. One of the things that we've noticed doing these cases, one of the rate-limiting step was dealing with the valves in the foot was very, very difficult. So what we started doing, we get plantar vein access with ultrasound guidance, as you can see here. And that's what the access looks like. We advance the wire. And the idea is to use that last vein, usually posterior tibial, and to make that conduit. And hopefully we get to deliver oxygen and blood to the foot and to the forefoot. So you can do it with multiple ways of crossing. You can use the Pioneer catheter, which we've used. We can use the Outback. You can use the Gansai technique, which is my favorite because it's cheap. It's the cheapest of all of them. And the lymphocatheter device as well, which we use in the clinical trial. So in this case, we use the Gansai technique. So we came down here after getting venous access, which I just showed you. We put a snare in the vein, snare the artery, we line them up, and we stick a 21-gauge needle. We use the cheapest wire that we can. In this case, we use a Cougar wire, it's $58. And we remove the needle and put the wires on both sides to establish connection between the artery and the vein. And after doing that, we use a forward balloon to make a channel. And you can see with the third picture, I'll show you the artery and the vein. And thereafter, we continue working. And dealing with the valves can be very, very difficult. We use regular balloons, we use cutting balloons, all kinds of way to deal with those. In this particular case, we did that, but we had a valve at the very last, but the ankle was very difficult. So after putting the cover stent, we post-dial it, we had difficulty. We use the modified pierce technique where we use a 18-gauge needle to pierce the valve externally so we can deal with that. And we're able to get the stent to open up nicely. This is another example of a situation we dealt with very similar to this. We found that we could not open this valve at all. And ultimately, an 18-gauge needle was able to take care of that and we were able to continue on. So for this particular case, this was the final result. We made that connection. We got the cover stent to deliver blood to the foot. And we expect the wound to get worse initially. So we don't forget when we see this, but we follow the patient very closely in collaboration with our podiatrist. And we saw in the PROMIS-1 trial that within the first month, actually the wound gets worse. So whenever these patients go to another hospital where they don't perform DVA, they always lose their leg because it looks worse. But for us, we know this, we take care of them. And the underwent a TMA, ultimately had a skin graft, a wound vac, and was able to heal his foot. Thank you for your attention.

peripheral artery disease

revascularization procedures

deep venous arterialization

blood flow restoration

wound healing