How I Do It: Distal Deep Venous Arterialization in the OBL

During a Wednesday afternoon session at ISET 2026, Mike Watts, MD, FSIR, from Atlantic Medical Imaging in New Jersey, presented a practical, real-world approach to performing distal deep venous arterialization (dDVA) in the office-based lab (OBL). Framed as a “how I do it” discussion, the presentation focused on patient selection, procedural setup, donor vessel choice, and technical decision-making that allow dDVA to be performed efficiently and reproducibly outside the hospital environment.

Dr. Watts emphasized that successful OBL-based dDVA begins long before the first wire crosses. Appropriate patients are active participants in their care, have a patent or reconstructible femoropopliteal segment, and can tolerate a prolonged procedure under moderate sedation. Equally important is the absence of contraindications to anticoagulation and active foot infection, reinforcing that patient selection remains the most critical determinant of outcomes.

From a procedural standpoint, he described a standardized setup that removes variability from the case. Antegrade common femoral artery access was described as non-negotiable, with full leg prep to at least the knee and parallel sterile workspaces at both the groin and the foot. Continuous ultrasound availability throughout the case was highlighted as essential, not optional, particularly when navigating distal anatomy and confirming targets.

Dr. Watts advocated for distal donor vessels that provide relatively low flow to the foot, minimizing the risk of transient ischemia and ensuring that occlusion of the dDVA does not compromise native arterial perfusion. Ideally, arterial inflow and venous outflow reach the foot at similar times, creating a more physiologic balance. This philosophy guided donor vessel selection and anastomosis planning throughout the cases he presented.

Dr. Watts reviewed multiple strategies for creating the arteriovenous anastomosis, including re-entry devices and gun-sight techniques, as well as options for vessel preparation, stenting, and valve management. Case examples illustrated how anatomy and prior interventions influence these choices, including scenarios involving recurrent recoil after multiple inframalleolar revascularizations.

He concluded by underscoring that dDVA in the OBL can be both feasible and economically sustainable. When performed thoughtfully, cases can be completed in approximately 2 hours, are not inherently cost-prohibitive, and may benefit from à la carte billing structures. Routine follow-up angiography at 4 weeks and aggressive anticoagulation were presented as part of his standard protocol, with the reassurance that if spontaneous conversion is seen on follow-up ultrasound at 8 to 12 weeks, further revascularization is often unnecessary.