Wound Care After Deep Vein Arterialization: The DPM’s Role

Key Takeaways 

• Dr. Sage emphasizes infection source control, wound stabilization, and offloading while the DVA circuit matures, with careful consideration of wound closure and subsequent surgical timing. 

• Follow-up requires surveillance of circuit patency and wound progression; loss of previously detectable arterialized flow warrants prompt communication with the vascular team. 

• Close collaboration among podiatric and vascular clinicians, consistent sharing of wound assessments, and patient education about the months-long healing process are central priorities in Dr. Sage’s approach. 

After deep vein arterialization (DVA), what do you feel are the DPM’s most important priorities, and how should wound management—including debridement and offloading—differ, if at all, from care following conventional arterial revascularization? 

Much like as we have been trained in infection management in these situations, source control is essential. Abscesses, wet gangrene, gas, and acute osteomyelitis need debridement and removal.  It is okay to leave and monitor dry gangrene. We may need to plan repeat debridements, prior to DVA intervention, and we may need to do more debridements if we are forced to because of recurring infection, after DVA, but before our definitive surgery, to properly achieve source control. 

We do not want to close the skin on these patients prior to DVA intervention, and we do not want to close the skin at definitive amputation. In my experience, this will create too much tension on the wound and will lead to failure. It is okay to close the fascial layer, however a guillotine amputation is essential in these cases. We need create and maintain a stable wound until the circuit matures.^1,2  

While we are awaiting maturation of the circuit, I prefer povidone-iodine wet-to-dry dressings to keep the wound stable and prevent infection. While we are in this stage, we are not looking to use advanced tissue products and we are trying to keep the wound relatively dry. 

During follow-up, how do you distinguish an expected healing course from changes that warrant prompt vascular reassessment? What findings should podiatrists and other wound care clinicians be especially alert to? 

Edema is expected. We are taking an area that has not been getting proper circulation and sending lots of blood to the area.  Allowing the patient to hang the legs down is advised to allow for natural hydrostatic pressure and to encourage further formation of venous collaterals. 

New necrosis is expected. It may be superficial or deeper.  We are not to panic when this is seen.  We need to allow this to demarcate prior to further intervention. This might be due to steal from existing collaterals and not failure of the procedure. 

Pain is expected and it may be severe. It could be inflammatory pain, wound pain, reperfusion pain, neuropathic pain, or a combination of the above. Collaboration with the team on appropriate pain control is paramount. 

Patency should be assessed frequently as most of the stenosis or occlusions are found while awaiting circuit maturation. This can be assessed by a hand-held Doppler in the podiatrist's office but also could be done by a vascular lab with duplex TcPO₂ or digital subtraction angiography.  

Vascular specialists will continue to follow and typically perform duplex ultrasound  typically done at 1 week, 4 weeks, 3 months, 6 months and 1 year at the inflow artery, proximal 1/3 of the stented artery, the midsegment of the stented vein, the distal 1/3 of the segment and the outflow vein.  The AV circuit can be considered patent if pulsating flow can be heard plantar to the calcaneus. Duplex TcPO₂ is important because duplex examinations may miss stealing side branches which may hinder our healing of the wounds. This may be done in our offices or by our vascular colleagues. 

Findings that we need to be alerted to are the inability to hear arterialized flow in the subcutaneous spaces on the plantar heel, along with losing the ability to hear the flow on the handheld Doppler, that was present before. 

How should the DPM and vascular team coordinate decisions about the timing of further foot surgery, such as debridement or minor amputation, and what should patients and caregivers understand about the path toward healing and a functional limb? 

In the best situations, the DPM and the vascular team should see these patients together. The DPM typically sees the patient at least weekly, and the vascular team at least monthly until the wound is healed.