Purpose <p>To evaluate the efficacy and safety of balloon-only venous arterialization (BOVA) in patients with chronic limb-threatening ischemia (CLTI) and refractory ischemic ulcers after failed or no feasible conventional revascularization.</p> Materials and Methods <p>This multicenter retrospective cohort study included 56 limbs treated with BOVA at five Japanese institutions between May 2021 and December 2023. The primary efficacy outcome was 12-month complete wound healing, and the primary safety outcomes were 12-month freedom from major amputation and overall survival.</p> Results <p>The cohort was high-risk: 76.8% had diabetes, 87.5% were on hemodialysis, 50.0% were Rutherford category 6, and 85.7% were Wound, Ischemia, and foot Infection stage 4. All pedal arteries were occluded in 80.4% of limbs. The 12-month complete wound healing rate was 45.5% (median time: 128&#xa0;days). Freedom from major amputation, overall survival, and amputation-free survival were 83.5%, 54.6%, and 43.9%, respectively. Reintervention incidence was 5.58 procedures per person-year.</p> Conclusion <p>BOVA appears to be a feasible limb salvage strategy for patients with CLTI without conventional revascularization options.</p> Level of Evidence <p>Level 3b</p> Graphical Abstract <p></p>