Controlled Heel-Site Arteriovenous Vent via Venous Reimplantation on PTFE-Tibial Bypass: A Novel Adjunct in No-Vein Chronic Limb-Threatening Ischemia.

BACKGROUND: In no-vein chronic limb-threatening ischemia (CLTI), infrapopliteal prosthetic bypass remains a limb-salvage option but is limited by high distal resistance and graft-artery compliance mismatch. Standard distal adjuncts, including vein cuffs, patches, or distal arteriovenous fistulas, may be technically demanding when local tibial venous anatomy and the confined distal exposure do not allow a reliable conventional configuration. We describe a compact heel-site bypass-to-vein vent based on direct end-to-side venous reimplantation onto the PTFE graft immediately proximal to the arterial heel. CASE PRESENTATION: A controlled heel-site arteriovenous vent was created immediately proximal to the arterial heel of a distal polytetrafluoroethylene (PTFE)-anterior tibial artery (ATA) anastomosis in a 75-year-old man with recurrent CLTI, prior failed revascularizations, no usable autologous conduit, and single-vessel tibial runoff through the ATA. Intraoperative assessment showed paired deep veins accompanying the ATA of approximately 2.0-2.5 mm in external diameter with thin walls, making a conventional distal AVF/interposition configuration technically unfavorable. A calibrated oval venotomy was fashioned on the distal PTFE graft, and the proximal stump of the anterior tibial vein was reimplanted end-to-side onto the graft with an oblique takeoff to create a short, controllable bypass-to-vein vent. RESULTS: Postoperative computed-tomography angiography and serial duplex ultrasound surveillance demonstrated sustained patency of both the PTFE-ATA bypass and the heel-site vent, without hemodynamically significant stenosis, excessive shunting, venous hypertension, distal steal, graft thrombosis, or reintervention at 6 months. Rest pain resolved, and baseline ambulation was restored. CONCLUSIONS: This heel-site arteriovenous vent represents a compact, calibratable bypass-to-vein configuration that differs from conventional distal AVF adjuncts by using direct end-to-side venous reimplantation onto the PTFE graft immediately proximal to the arterial heel. Because established distal AVF and vein-cuff adjuncts are supported by a stronger evidence base, this configuration should be considered only as a fallback/adaptive option in selected no-vein CLTI scenarios when standard distal adjuncts are technically infeasible.