Navigating the Waters of Hope: Patient-Centric Perspectives on Percutaneous Deep Venous Arterialization Reintervention
Zola N’Dandu, MD
J CRIT LIMB ISCHEM 2023;3(4)E155-E156. doi: 10.25270/jcli/OEM23-00010
J CRIT LIMB ISCHEM 2023;3(4)E161-E162. doi: 10.25270/jcli/OEM23-00010
Key words: percutaneous deep venous arterialization, chronic limb-threatening ischemia
In the realm of vascular interventions, percutaneous deep venous arterialization (pDVA) has emerged as a beacon of hope for patients grappling with the challenges of chronic limb-threatening ischemia (CLTI). As we delve into the intricacies of pDVA reintervention, the focus must remain unwavering on the individuals at the heart of these procedures—our patients.
A Glimpse Into Reintervention Realities
The journey through and after the index pDVA procedure is, for many patients, a multifaceted experience. The recent retrospective study by Zaman, et al, “Outcomes of Reintervention in Percutaneous Deep Venous Arterialization,” sheds light on the nuances of reintervention after pDVA performed with “off-the-shelf” devices, revealing that approximately 33.9% of cases necessitated a clinically driven reintervention, with predisposing conditions such as hypertension playing a role. It is not merely a statistical exploration but a narrative of individuals facing the ebb and flow of rest pain, wound healing, and the prospect of limb salvage. Patients requiring reintervention needed various procedures, including balloon angioplasty of the donor artery or plantar vein outflow, stenting of the covered stent edge restenosis, thrombectomy, and coiling of foot vein branches to optimize maturation of the circuit with the goal of limb salvage. These strategies are needed to optimize the performance and longevity of the circuit. We should refer to them as optimization steps rather than reintervention procedures.
The patient-centric narrative of pDVA reintervention extends beyond statistical insights into the tangible impact on individual lives. Particularly illuminating is the divergence in amputation trends between the non-reintervention and reintervention groups. Within the initial 3-month interval, a stark contrast unfolds: all reported amputation events manifested in the non-reintervention group, while merely 1 patient required a major amputation within the reintervention cohort. This stark difference suggests that reintervention, within this period, potentially averted or mitigated severe outcomes for most patients. A nuanced narrative emerges as we extend our gaze to the 6-month mark. In the reintervention group, only 2 reported amputations signify a more gradual amputation rate than their non-reintervention counterparts. This temporal lens unveils an interesting patient story, where those in the reintervention group navigate the prospect of amputation with a more measured cadence, underscoring the potential protective effect of reintervention. There is a phenomenon of sustained limb perfusion improvement in arterialization, even after the circuit is occluded. Observational studies often notice this sustained improvement around 6 to 8 weeks after the index procedure. The sustained improvement in perfusion in the nonintervention group, potentially because of angiogenesis after creating a DVA circuit from pressuring the capillary bed through the arterialized vein, could explain the contrast in amputation timing between the intervention and nonintervention groups. Based on this observation, the patients in the nonintervention group might have been above the healing threshold, preventing major amputations after the 3-month mark.
The temporal aspect of reintervention introduces a compelling narrative arc. The study suggests an initial surge of benefit, with considerable improvement in CLTI symptoms and wound healing within the first month post reintervention. However, as time unfolds, the waves of improvement seem to recede, prompting reflections on the long-term sustainability of these gains.
Enabling patients to take contro becomes a central focus of this narrative. Recognizing the unpredictability of clinical trajectories, the authors of “Outcomes of Reintervention in Percutaneous Deep Venous Arterialization” propose a paradigm shift toward proactive pDVA surveillance. Our practice, for instance, has embraced the “second look” angiography at a 1-month post-procedure described by the authors. Additionally, we have also implemented a surveillance protocol using skin perfusion pressure, transcutaneous oxygen pressure, and certain Doppler parameters, such as pDVA conduit flow volume and mid-conduit peak systolic velocity. This compilation of data not only provides a platform for identifying and addressing issues but also instills a sense of control in patients actively participating in their care.
Behind the statistics and procedural intricacies lies the human factor. The editorial team would like to underline that the decision for reintervention is not just a clinical calculus but a deeply personal choice, where patients, armed with the knowledge of potential benefits and limitations, navigate their path toward enhanced well-being in collaboration with their health care providers. As we reflect on the statistics and outcomes, it is crucial to consider the stories within—the individual who experiences the relief of pain, the joy of healed wounds, and the renewed hope for a functional limb. Each percentage in the study represents a person, and understanding the patient journey illuminates the true impact of pDVA reintervention.
A Patient-Centric Future
In conclusion, we are initiating a call to action for a patient-centric future. Future research endeavors in the space of DVA should not only refine technical aspects but also seek to better understand the proper surveillance methods and clinical indications of reintervention. A holistic approach, acknowledging the emotional, psychological, and cultural dimensions, harmonized with cutting-edge technology to compose a melody of healing. As we advance the technical aspect of pDVA, we should also elevate the human experience, ensuring that every patient’s journey is a testament to compassionate and comprehensive care. In the waters of hope, we should always ensure that patients stand at the helm and our compass is oriented toward their well-being. Hopefully this patient-centric editorial strives to bridge the gap between clinical insights and the human stories woven into the fabric of pDVA reintervention.
From the Ansaarie Cardiac and Endovascular Center of Excellence, East Palatka, Florida.
Disclosure: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. N'Dandu reports that he was the principal investigator for the PROMISE II landmark study.
Address for correspondence: Zola N’Dandu, MD, Ansaarie Cardiac and Endovascular Center of Excellence, 215 Highway 17, East Palatka, FL 32131 Email: email@example.com