Research-Driven Care Transforms Outcome for Patient Facing Leg Amputation

PROMISE II study offers hope

At the Wound Center, burn surgeon Jeremy Goverman, MD, said that John's big toe would need to be surgically removed. He also warned that, without intervention, John faced the possibility of a leg amputation. However, Dr. Goverman presented an alternative: the PROMISE II study. Mass General was one of 19 U.S. sites participating in the trial, which was evaluating deep venous arterialization (DVA) as a potential limb-saving option for patients with CLTI.

To help John explore his options, Dr. Goverman referred him to vascular surgeon Anahita Dua, MD, one of the country's only vascular surgeons who performs DVA. She is co-director of Mass General's Limb Evaluation and Amputation Prevention Program and on the faculty of the Mass General Brigham heart and vascular faculty.

Dr. Dua quickly concluded that John had no blood circulation in his left foot, putting his left leg in grave danger. Conventional surgical options would not restore blood flow, and she worried about the consequences of amputating the leg.

"With the rise in diabetes, we're seeing more and more patients with no blood flow in the legs," she said. "However, amputation can lead to inactivity, increasing the risk of heart problems, stroke, depression, and even death. I see DVA as not just a leg-saving procedure but also a lifesaving one."

Dr. Dua is among the Mass General doctors who helped develop and refine DVA through the PROMISE II study and others. As she explained, healthy arteries carry blood from the heart to various parts of the body, and veins bring blood back to the heart. But in patients with CLTI, the veins are sitting empty because no artery blood is getting to the foot.

"With DVA, we 'hijack' those inactive veins and reverse the flow. Instead of sending blood back up to the heart, we redirect it from the heart down to the toes," she said. "We can deliver oxygenated, nutrient-rich blood to an area of the body that otherwise has no chance of getting it, thereby saving the leg."

Surgery restores blood flow

One day after seeing Dr. Goverman, John had surgery at Mass General to remove the frostbitten toe. Unfortunately, the second and third toes on his left foot quickly turned gangrenous. Podiatric surgeon Sara Rose-Sauld, DPM, amputated these toes during the same procedure in which Dr. Dua performed DVA.

John spent two weeks recovering at Mass General. Ultrasound testing before and after his discharge showed promising results. By three months, there was clear evidence that normal blood flow had returned to the bottom of his leg. This progress allowed Drs. Dua and Rose-Sauld to surgically reshape what remained of his left foot for optimal walking.

Still, the two years following DVA were tough for John. He had to use a knee scooter and a wound vacuum for months on end, and he underwent surgery to treat a dangerous infection in his left foot. More procedures followed, first to remove the infected big toe on his right foot, and later to extract two bones from his second toe due to infection. (Both infections were related to the lack of blood flow to the right foot.)

Through it all, he remained a model patient. "He's a great listener who really partnered with us to help save his leg, and that's made a big difference in his recovery," Dr. Dua said.

Proven system leads to positive outcome

Three years after the DVA surgery, John is thriving. He wears a special shoe on his left foot with built-in cushioning, allowing him to walk with ease. His speed and balance continue to improve every day.

"DVA isn't a standalone procedure; it requires a system. And Mass General has one of the best systems in the world for DVA," Dr. Dua said. "The reason John has done so well is because we provide the support, scientific excellence, surgical expertise, wound care, ultrasound monitoring, and long-term follow-up care for patients requiring DVA."

Reflecting on his journey, John acknowledges the challenges but is thankful for how far he has come.

"I'm really enjoying my quality of life. To be able to do the things I can is miraculous," he said. "My affection for Mass General and the people who work there is off the charts. I'm blessed. Absolutely blessed."