Long-Term Outcomes in Patients With Peripheral Arterial Disease Who Undergo Free Flap Reconstruction for Chronic Lower Extremity Wounds

Abstract

Background Free tissue transfer (FTT) is critical for limb salvage of chronic lower extremity (LE) wounds. In patients with peripheral arterial disease (PAD), FTT LE reconstruction can be challenging due to limited vessel selection for anastomosis. The study aims to evaluate our surgical and functional outcomes after FTT to LE in patients with PAD. Methods A retrospective review identified patients who underwent LE free flap reconstruction between 2011 and 2021. All patients underwent preoperative arteriogram and subsequent FTT. Patients were classified into PAD or non-PAD cohorts, based on the presence of LE arterial stenoses or occlusions identified on arteriogram. Primary outcomes included complications, flap success, need for post-FTT vascular reintervention, limb salvage, and ambulatory status. Results A total of 253 patients underwent FTT to LE, with 84 patients (33.2%) in the PAD cohort. Patients with PAD had a higher prevalence of diabetes (83.3% vs 39.1%, P < 0.001) and end-stage renal disease (8.3% vs 2.4%, P = 0.028). Osteomyelitis was more common in the PAD group (73.8% vs 55.0%, P = 0.004). Free tissue transfer donor sites and flap composition were similar between cohorts. At a mean follow-up of 21.1 months, limb salvage rates were similar between non-PAD and PAD cohorts (90.5% vs 84.5%, P = 0.158), with no significant differences in ambulatory status or mortality. Higher complication rates occurred in the PAD cohort (38.1% vs 20.7%, P = 0.003), of which partial flap necrosis was more prevalent in the PAD group (6.0% vs 0.6%, P = 0.016). There was no difference in flap success rates between groups (P = 0.430). More postflap angiograms were performed in the PAD group (29.8% vs 7.1%, P < 0.001), with repeat percutaneous endovascular intervention performed in 68.0% of the PAD group versus 33.3% of the non-PAD group (P < 0.001). Conclusions This is the largest study to demonstrate excellent long-term limb salvage outcomes in patients with PAD who undergo FTT to LE. Percutaneous endovascular intervention and FTT are effective methods to achieve limb salvage in vasculopathic patients with chronic LE wounds.

Comparison of Postoperative Complications in Patients Undergoing Limb Salvage Reconstructive Surgery Based on Estimated Prevalence of Preexisting Peripheral Arterial Disease

“…Regarding nontraumatic free flap reconstruction, Kolbenschlag et al 3 found that angiography-confirmed PAD was associated with higher flap loss rates, and Lese et al 19 found that risk factors for PAD were linked to greater risk of vascular compromise and flap failure. In addition, Bovill et al 7 found that PAD was associated with higher complication rates but similar flap success rates compared with non-PAD patients. Despite reports of PAD-associated complications, the overwhelming conclusion of existing literature is that PAD should not preclude free tissue transfer in LE reconstruction 3,7,14,15 .…”

“…In addition, Bovill et al 7 found that PAD was associated with higher complication rates but similar flap success rates compared with non-PAD patients. Despite reports of PAD-associated complications, the overwhelming conclusion of existing literature is that PAD should not preclude free tissue transfer in LE reconstruction 3,7,14,15 . Our findings suggest that high PAD risk may be associated with decreased flap survival and may prove important for reconstructive surgeons to consider when treating LE trauma.…”

“…6 Peripheral arterial disease (PAD) complicates microsurgical reconstruction by impeding oxygenated blood flow to the LEs and limiting the availability of patent vessels for free flap anastomosis. 7 Peripheral arterial disease is estimated to affect approximately 7% (8.5 million adults) of the US population age 40 years and older, and up to 50% of patients are asymptomatic, making it difficult to assess its true prevalence. [8][9][10][11] Therefore, PAD is often undiagnosed and undertreated.…”

“…Although PAD was previously thought to increase the risk of free flap failure, several studies have shown that PAD does not negatively affect flap survival and should not be considered an absolute contraindication for LE salvage. 3,7,14,15 However, there is limited published literature on the effects of PAD on outcomes in posttraumatic LE reconstruction. 16 In this study, we use a validated risk assessment tool to estimate patients' risk of having undiagnosed PAD and evaluate outcomes after LE reconstruction at a level 1 trauma center.…”

“…Although PAD was previously thought to increase the risk of free flap failure, several studies have shown that PAD does not negatively affect flap survival and should not be considered an absolute contraindication for LE salvage 3,7,14,15 . However, there is limited published literature on the effects of PAD on outcomes in posttraumatic LE reconstruction 16 .…”