Superficial venous arterialisation for chronic limb threatening ischaemia

Evidence-based recommendations on superficial venous arterialisation for chronic limb threatening ischaemia in adults. This involves joining an artery in the lower leg to a large vein to divert blood flow through the vein towards the foot, bypassing the blocked arteries.

# Recommendations
Evidence on the safety of superficial venous arterialisation for chronic limb threatening ischaemia shows well-recognised complications. Evidence on its efficacy is inadequate in quantity and quality. However, in people with no other option for revascularisation, this procedure can be used with special arrangements for clinical governance, consent, and audit or research. Find out what special arrangements mean on the NICE interventional procedures guidance page.
Clinicians wanting to do superficial venous arterialisation for chronic limb threatening ischaemia should:
Inform the clinical governance leads in their healthcare organisation.
Give people (and their families and carers as appropriate) clear written information to support shared decision making, including NICE's information for the public.
Ensure that people (and their families and carers as appropriate) understand the procedure's safety and efficacy, and any uncertainties about these.
Audit and review clinical outcomes of everyone having the procedure. The main efficacy and safety outcomes identified in this guidance can be entered into NICE's interventional procedure outcomes audit tool (for use at local discretion).
Discuss the outcomes of the procedure during their annual appraisal to reflect, learn and improve.
Healthcare organisations should:
Ensure systems are in place that support clinicians to collect and report data on outcomes and safety for everyone having this procedure.
Regularly review data on outcomes and safety for this procedure.
Patient selection should be done by a multidisciplinary team with specialist expertise in managing chronic limb threatening ischaemia.
The procedure should only be done in specialist centres by surgeons with specific training and experience in this procedure.# The condition, current treatments and procedure

# The condition
Chronic limb threatening ischaemia (CLTI), also known as critical limb ischaemia, is a severe blockage in the arteries of the lower extremities. It is an advanced stage of peripheral arterial disease. CLTI is characterised by severely diminished circulation, ischaemic pain, ulceration, tissue loss or gangrene. It is associated with high amputation and mortality rates, and poor quality of life.

# Current treatments
CLTI needs urgent treatment to re-establish blood flow to the affected area and to prevent major amputation. Treatment options include medications, endovascular interventions (such as angioplasty, stents, laser atherectomy and directional atherectomy) and surgical treatments (such as bypass). Management of CLTI is described in NICE's guideline on peripheral arterial disease.

# The procedure
Preoperative investigation (such as angiography, arterial and venous duplex scan) is needed to assess the vascular system and its blood flow. During the operation, an arteriovenous fistula is created between the great saphenous vein (GSV) and the appropriate patent artery. The GSV is then anastomosed endtoside to the artery below the knee. Side branches of the GSV to the ankle level are ligated and valvulotomy is done.
This procedure arterialises the venous arch of the foot, with GSV maintained in situ and without compromising the existing collateral circulation. The aim is to improve symptoms and salvage the affected lower extremity.