Extension of limb salvage by combined vascular reconstruction and adjunctive free-tissue transfer

Abstract

Vascular reconstruction alone can be insufficient for extremity salvage in some patients with severe soft-tissue wounds. We present our experience in 20 patients with vascular reconstruction for ischemic disease and free-tissue transfer for limb-threatening soft-tissue wounds. Methods: Nineteen patients underwent autogenous venous bypasses and one patient underwent an aortobifemoral bypass. Ten soft-tissue reconstructions were performed at the time of the vascular reconstruction and 10 were delayed. Free-tissue transferred included muscle, fasciocutaneous flaps, and omentum. Inflow to the flap was from the bypass graft (n = 12) or the distal tibial artery. Results: One free flap and graft failed immediately in the same patient. One successful flap and graft required a below-knee amputation for ongoing infection in the surrounding soft tissues. Eighteen of 20 patients have had free-flap and graft patency during the mean follow-up period of 17 months (range 6 to 33 months). These 18 patients ambulate independently. Conclusions:In patients with arterial insufficiency and severe soft-tissue wounds, combined vascular reconstruction and free-tissue transfer permits extended limb salvage with excellent functional results. (J VASC SURG 1993;18:972-80.) Limb-threatening, lower extremity soft-tissue wounds are a frequent manifestation of arterial occlusive disease. Successful arterial bypass alone is insufficient for complete lower extremity reconstruction in patients with exposed tendon or bone proximal to the metatarsal-phalangeal joints. Before the advent of free-tissue transfer, these severely ischemic wounds of the distal leg, ankle, and foot were treated with amputation. Combined vascular reconstruction with free-tissue transfer (VR-FTT) for coverage of these wounds permits extended limb salvage.

Management of ischemic heel ulceration and gangrene: An evaluation of factors associated with successful healing

“…1,2,11,12 No standard management protocol for these wounds currently exists, 5 but, using a variety of approaches, some centers have now reported up to 90% limb-salvage rates in selected patients. 5,4,11,[13][14][15][16][17][18][19] However, there have been very few recent studies evaluating the results of treatment for these wounds, and most older reports have been from a single institution and have involved a small number of patients. No recent reports have specifically examined the influence of patient demographic factors, hemodynamic and arteriographic findings, and cardiovascular risk factors on wound healing.…”

Combined free tissue transfer and infrainguinal bypass graft: An alternative to major amputation in selected patients

“…Details of free tissue transfer at our institution have been previously described. 1 Bypass grafting is performed in conventional fashion with tourniquet control of tibial vessels. Flaps are harvested from various sites according to coverage and contour needs, as well as logistics of operation when simultaneous procedures are performed.…”

Impact of the Timing of Foot Tissue Resection on Outcomes in Patients Undergoing Revascularization for Chronic Limb-Threatening Ischemia

“…24 Other studies have demonstrated extensive multiple procedures, such as revascularization combined with free or pedicled flaps, are best performed in a staged fashion given the length and complexity of the operation. [25][26][27] Yet, the literature regarding timing for less extensive procedures such as minor amputations and debridement after revascularization for CLTI is sparse.…”