In the management of patients with critical limb ischemia endovascular revascularization plays a crucial role improving amputation-free survival, ischemic rest pain, and wound healing. Endovascular standard of care of peripheral arterial occlusive disease involves angioplasty and/or stent placement. The following discussion is intended to familiarize interventional physicians with the rationale, physiological concepts, and technical approach to developing endovascular procedures-percutaneous femoropopliteal bypass and percutaneous deep vein arterialization. Percutaneous arterial bypass procedure is designed to treat long complex Trans-Atlantic Inter-Society Consensus C and D hemodynamically significant superficial femoral artery lesions by redirecting the flow of blood from the diseased arterial segment through a femoral vein conduit. Percutaneous deep vein arterialization is used for selected "no-option" critical limb ischemia patients who cannot undergo or have failed conventional endovascular and/or surgical revascularization due to extensive occlusion of the outflow arteries. It involves creation of an arteriovenous fistula between a tibial artery and a tibial vein, disruption of venous valves, and elimination of venous collaterals. The consequent arterialization of the distal venous bed enables delivery of oxygenated pressurized arterial blood to the ischemic tissues, stimulating angiogenesis and increasing flow in the existent collateral vessels, which in turn will improve limb salvage and amputation free survival.
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