Limb Salvage Rates and Functional Outcomes Using a Longitudinal Slit Arteriotomy End-to-Side Anastomosis for Limb-Threatening Defects in a High-Risk Patient Population

Abstract

Background: Limb salvage techniques using free tissue transfer in patients with chronic wounds caused by longstanding osteomyelitis, diabetes, and peripheral vascular disease are technically challenging. The longitudinal slit arteriotomy end-to-side anastomosis is the authors’ preferred technique because it is the least invasive arteriotomy and is especially important for diseased recipient arteries. The authors reviewed highly comorbid patients who underwent free tissue transfer with this technique to understand the success rates, overall outcomes, and long-term limb salvage rates. Methods: A retrospective review was performed to analyze outcomes of free tissue transfer using longitudinal slit arteriotomy end-to-side anastomosis between 2012 and 2018 performed by the senior surgeon (K.K.E.). Results: One hundred fifteen free flaps were identified. Patients were, on average, 55.9 years old, with a body mass index of 29.2 kg/m2. Comorbidities included osteomyelitis (83.5 percent), hypertension (60.9 percent), tobacco use (46.1 percent), diabetes (44.3 percent), peripheral vascular disease (44.3 percent), hypercoagulability (35.7 percent), and arterial calcifications (17.4 percent). Overall flap success was 93.0 percent; 27.8 percent required reoperation perioperatively because of complications. On univariate analysis, diabetes mellitus, hypertension, and hypercoagulability were significantly associated with eventual amputation (p < 0.05). Multivariate analysis showed that intraoperative thrombosis and take back was independently associated with flap failure. There was an overall limb salvage rate of 83.5 percent, and of those salvaged, 92.7 percent were ambulating without a prosthesis at a mean follow-up of 1.53 years. Conclusions: This is the largest series of longitudinal slit arteriotomy end-to-side anastomosis for patients undergoing free tissue transfer for limb-threatening defects in the compromised host. Overall flap success, limb salvage rates, and functional outcomes are high using this technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Free flap reconstruction of plantar weight‐bearing heel defects: Long‐term functional and patient‐reported outcomes

“…The senior author additionally prefers using FTT with the longitudinal slit arteriotomy end‐to‐side anastomosis technique in order to provide necessary blood flow with vascularized tissue to the area of localized ischemia in these patients. Previous results using this technique at our institution found high long‐term patency rates following the procedure (Black et al, 2020). In the current study, PVD patients experienced a 61.1% rate of limb salvage despite their ischemic state.…”

The Need to Improve Patient-Centered Outcome Reporting Following Lower Extremity Flap Reconstruction: A Systematic Review and Meta-analysis

“…Multiple studies focused on the use of ambulation-assisted devices, 31,40 while others focused instead on the ability to ambulate unassisted. 44,49,61 Other measures of function, such as return to baseline function and change from preoperative ambulation status, were described sparingly and without comparability to outcomes published in other studies. Moreover, few studies used validated scales, such as the LEFS or FAC, to report functional status in a standardized fashion.…”

“…14,44,46,50 Ambulation rate was reported by 14 studies, with a weighted mean of 83.3% of patients ambulating postoperatively. 14,31,37,40,44,50,[52][53][54]56,58,[61][62][63] The average LEFS score, calculated from three studies, was 54.4 out of 80 points, indicating stage-4 function, or "independent community ambulation." 14,44,46 The range of LEFS scores was 46 to 65.6, with the highest score reported by Wu et al in a study of local flap outcomes for chronic osteomyelitis of long bones.…”

Expanding Criteria for Limb Salvage in Comorbid Patients with Nonhealing Wounds: The MedStar Georgetown Protocol and Lessons Learned after 200 Lower Extremity Free Flaps

“…23 We perform a longitudinal slit arteriotomy end-to-side anastomosis for the arterial anastomosis as outlined in a prior study and dual venous anastomoses to increase outflow. 15 A saphenous interpositional vein graft is used when both flap and recipient arteries are found to be severely calcified. 24 The Cook Doppler (Cook Medical, Bloomington, Ind.)…”