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.
Background: Free tissue transfer (FTT) reconstruction is associated with a high rate of limb salvage in patients with chronic lower extremity (LE) wounds. Studies have shown perioperative risk stratification tools (e.g., modified 5-factor frailty index (mFI-5) and Charlson Comorbidity Index (CCI)) to be useful in predicting adverse outcomes; however, no studies have compared them in patients undergoing LE reconstruction. The aim of this study is to compare the utility of mFI-5 and CCI in predicting postoperative morbidity in elderly patients receiving LE FTT reconstruction.
Methods: A retrospective review of patients >60 years who underwent LE FTT reconstruction from 2011-2022 was performed. Comorbidity burden was measured by two validated risk-stratification tools: mFI-5 and CCI. Primary outcomes included prolonged postoperative length of stay (LOS), defined as >75th percentile of the cohort, postoperative complications, and eventual amputation.
Results: One-hundred fifteen patients were identified. Median CCI and mFI-5 were 5 (IQR 4,6) and 2 (IQR 1,3), respectively. Average postoperative LOS was 16.4 days. Twenty-nine patients (25.2%) experienced a postoperative complication, and eight patients (7.0%) required LE amputation at a mean follow-up of 19.8 months. Overall flap success was 96.5% (n=111), and limb salvage rate was 93% (n=108). Increased CCI was found to be independently predictive of only eventual amputation (OR 1.59, p=0.039), while mFI-5 was not predictive of prolonged postoperative LOS, flap complications, or eventual amputation.
Conclusion: This is the first study to compare the utility of mFI-5 and CCI in predicting adverse outcomes in elderly patients undergoing LE FTT reconstruction. Our results demonstrate CCI to be a superior predictor of secondary amputation in this patient population and mFI-5 to have limited utility. Further investigation in a prospective multicenter cohort is warranted.
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