# Fenestrated Transcatheter Arterialization of the Deep Veins: Protecting the Peroneal While Covering the Tibioperoneal Trunk

## TL;DR

A new method for treating leg ischemia uses a stent graft to connect an artery to a vein while preserving blood flow to the peroneal artery.

## Contribution

A novel fenestrated stent graft technique is introduced to maintain peroneal flow during TADV in patients with unsuitable tibial arteries.

## Key findings

- The Culotte 2-stent bifurcation technique allows peroneal flow preservation while deploying a covered stent graft.
- Plantar venous access and graft inflow/outflow optimization are critical for successful TADV outcomes.
- Alternative inflow TADV can maintain native arterial perfusion during graft maturation.

## Abstract

We describe a novel approach to transcatheter arterialization of the deep veins (TADV) in a patient with chronic limb-threatening ischemia using the LimFlow kit and a Culotte 2-stent bifurcation technique to maintain peroneal flow while deploying a covered stent graft into the tibioperoneal trunk and posterior tibial vein when there is no tibial artery suitable for the TADV inflow.

(1) Antegrade access of the superficial femoral artery and ipsilateral lateral plantar vein, (2) crossover wire from the artery into the vein, (3) place the LimFlow stent graft connecting the artery to the vein, (4) fenestrate the stent graft to allow bifurcation stenting into the peroneal artery to preserve native peroneal flow, and (5) optimize the inflow and outflow from the graft.

Plantar venous access, compromising native arterial flow, and graft inflow/outflow issues require careful consideration during and after the TADV procedure.

Alternative inflow TADV is feasible to maintain native arterial perfusion while the TADV circuit matures.