Free flap ?steal? hastening amputation of a revascularized lower limb

Abstract

European ]['~hl ,dO %na, of lff_lflS[lC bu¢ ery Abstract. Complex limb threatening wounds secondaryto end-stage atherosclerotic peripheral occlusive disease remain significant challenges that frequently mandate vascularized tissue coverage that can only be achieved with a microsurgical composite tissue transfer. Following or concurrent with limb revascularization, the theoretical risk that such a free flap could divert flow to a comparably lower resistance system of the flap has been previously considered hypothetical. We present a case report where we believe such a "steal syndrome" did occur as suggested by arteriogram, and this adverse phenomenon hastened limb amputation. This possible risk must be carefully explained and accepted by these patients prior to embarking on these complex limb salvage attempts.

Pedicled SCIA and SIEA Mega Groin Flap-A Staged Reconstructive Approach for Large Forearm Defects

“…A steal phenomenon resulting from an upstream installation of a free flap can lead to circulatory compromise 6) and ultimately Volkmann's ischemic contracture of the forearm in our cases. Therefore, we elected to leave the forearm circulation undisturbed to allow for recovery of the muscles and even neovascularization of a large skin flap.…”

“…The pedicled groin flap still has its role particularly in crush-degloving injuries of the upper extremity where the vascularity of the recipient site is compromised. In such scenarios, performing a free flap could potentially cause further ischemia because of the steal phenomenon, which has been described in the lower extremities 6) .…”

Impact of the Successful Flap but Failed Reconstruction on the True Rate of Success in Free-Tissue Transfers

“…The successful free flaps, but failed reconstructions, had a myriad of presentations (see Table 2). Progressive vascular ischemia, unrelated to the flap in three patients, with a "steal" phenomenon in one, 9 could be solved only by limb amputation. Infection persisted in two cases, and recurred in two others, with only one of the latter salvaged with a skin graft; the other three had limb amputations.…”

Blood flow in free micro-vascular flaps

“…It would seem that during the first postoperative months the free flap promoted indirect revascularization of the ischaemic recipient site (101), thus allowing the foot and the flap itself to survive despite graft occlusion. However, in some cases the free flap has been held responsible for foot necrosis and eventual limb amputation (109,153). The flap may steal blood from the bypass, thus impairing the precarious circulation in the distal part of the lower extremity.…”