Duplex protocol and evaluation of the LimFlow transcatheter arterialization of deep vein (TADV) procedure

Chronic limb-threatening ischemia (CLTI) poses a major revascularization challenge, especially in no-option patients. Transcatheter Arterialization of the Deep Vein (TADV), using the LimFlow system (Stryker, Irvine, CA), offers a novel endovascular solution by creating a fistula between the tibial artery and deep tibial vein. This reroutes oxygenated blood to the distal foot, improving perfusion to ischemic tissue. LimFlow has advanced TADV through specialized instruments and duplex ultrasound protocols, supported by seven years of clinical trials (PROMISE I–III and PROMISE UK). Herein, we standardize the underlying duplex protocol to enhance post-procedure management, improve reproducibility, and support better outcomes in this high-risk population. This article details the duplex ultrasound protocol for both pre- and post-operative evaluation of TADV. The pre-operative assessment includes mapping the lateral plantar vein (LPV), ruling out deep vein thrombosis (DVT), and evaluating LPV size for percutaneous access. Post-operative imaging assesses arterial flow, TADV patency, collateral formation, and flow volume. We also report an optimal flow range associated with wound healing and collateral development. The protocol demonstrates that sonographer expertise is critical, as inaccurate flow measurements can misrepresent hemodynamics.