“Patients previously considered ‘no-option’ may no longer truly be without options,” said Anahita Dua, MD, associate professor at Harvard Medical School and a vascular surgeon at Massachusetts General Hospital. That assertion sums up the central finding of an analysis comparing deep vein arterialization (DVA) with the current standard of care for no-option chronic limb-threatening ischemia (CLTI) which Dua presented during the Women’s Section session at VAM 2026.
No-option CLTI represents the most severe end of the peripheral artery disease spectrum, encompassing patients who have exhausted conventional revascularization options and face extremely high rates of major amputation and death. Historically, once classified as no-option, clinical conversations shifted from limb salvage toward amputation planning. DVA offers an alternative by routing oxygenated arterial blood retrograde through the venous system to perfuse ischemic foot tissue, bypassing the absence of viable distal arterial targets entirely.
“What makes DVA so important is that it creates a pathway to perfuse tissue in patients who otherwise have no distal arterial targets available for conventional revascularization,” said Dua. “In many ways, it transforms a previously unsalvageable limb into one with a realistic opportunity for healing and preservation.”
The study compared outcomes from the PROMISE trials with those from the CLariTI registry, a prospective observational study reflecting the natural history and standard-of-care management of no-option CLTI patients. At one year, limb salvage rates reached approximately 71% in the DVA cohort versus 50% in the standard-of-care cohort. Amputation-free survival was also significantly improved, as were wound healing trajectories, with many patients progressing from nonhealing wounds toward outcomes Dua describes as historically unlikely.
“The most striking finding was the magnitude of benefit observed with DVA compared with standard care,” said Dua. “That consistency across prospective trials and real-world practice is incredibly encouraging and suggests this is not an isolated signal but a therapeutic advance for no-option CLTI patients.”
Major amputation in this population carries serious consequences, including loss of independence, recurrent hospitalizations and high mortality, making even incremental gains in limb salvage clinically important. Dua argued that DVA’s benefit must be weighed against all of those realities, not simply the technical outcome of the procedure itself. “The procedure is not simply about saving a limb anatomically,” she said. “If we can safely reduce amputations in this population, the impact extends far beyond the operating room.”
Dua said the study also raises a timely question about sequencing. Traditionally reserved as a last resort, DVA’s strong performance prompts reconsideration of whether earlier intervention, specifically in rest pain patients before tissue loss becomes irreversible, could improve outcomes further. Success also requires surrounding infrastructure, including coordinated wound care, infection management, anticoagulation, offloading and multidisciplinary follow-up.
Dua said further research into wound-healing biology, microvascular remodeling after DVA and optimal antithrombotic strategies for maintaining long-term patency is needed. Identifying perfusion-based or imaging biomarkers to sharpen patient selection is another priority, alongside expanded real-world data across broader populations and health care systems.
“The next step is to better define which patients benefit most, when intervention should occur and how we optimize perioperative and postprocedural management,” said Dua. “There is still tremendous opportunity to refine patient selection and improve durability and continued evaluation will help establish DVA as a durable standard within modern limb preservation programs.”
For a population that has long had few options, Dua said those possibilities represent a fundamental shift in what the disease trajectory can look like. “For many of these patients, DVA is an opportunity to preserve independence, mobility and quality of life when amputation once seemed inevitable,” she said.
