A2VF Technique: Venous-Puncture-Free Foot Arteriovenous Fistula Creation in Chronic Limb-Threatening Ischemia.

OBJECTIVE: This study aimed to describe the antegrade arteriovenous fistula technique, an intravascular ultrasound-guided arterial approach for foot arteriovenous fistula creation without percutaneous venous puncture or venous sheath insertion. KEY STEPS: In a patient with no-option chronic limb-threatening ischemia, intravascular ultrasound was used to identify a distal posterior tibial artery segment with a less calcified arterial wall window and an adjacent, visible posterior tibial vein. A hard-tip guidewire supported by a microcatheter was advanced from the artery into the vein, followed by guidewire navigation into the plantar venous arch, valvotomy, and venous tract dilatation. POTENTIAL PITFALLS: Severe circumferential calcification, inadequate visualization of the target vein, and distal vessel angulation may limit technical success. TAKE-HOME MESSAGE: The antegrade arteriovenous fistula technique may remove the need for direct venous access during foot arteriovenous fistula creation in selected patients.