Evidence of nutritional vascular formation from the “nutrient flap” in a patient with no-option chronic limb-threatening ischemia: An indocyanine green fluorescence imaging study

Kagaya, Yu; Ohura, Norihiko; Mori, Shinsuke; Ozaki, Mine

doi:10.1016/j.jvscit.2022.05.004

Cited by 1 publication

(3 citation statements)

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“…The arterial source of the present flap was high-flow (superficial femoral artery). Thus, a nutrient vascular formation to the surrounding ischemic tissue (Kagaya et al, 2022) was likely to occur. The dyeing of the surface of the foot area using the ICG bypass-through angiography was considered not only owing to the arterio-venous shunt but also because of the nutritional blood flow from the flap.…”

Section: Discussionmentioning

confidence: 99%

“…In this case, the main purpose of the free flap transfer was coverage of the unhealed wound. However, the flap possibly served as a nutrient source as well (called a nutrient flap) (Horch et al, 2014; Kagaya et al, 2022; Kwon et al, 2022), thus retaining viability of the ischemic foot. Other options for wound coverage can be a free cross leg flap (Manrique et al, 2018) or a supermicrosurgical perforator flap using the collateral recipient arteries (Suh et al, 2016).…”

Section: Discussionmentioning

confidence: 99%

“…The double run‐off route of the flap and arterio‐venous shunt could yield low vascular resistance and high blood flow (Eweida et al, 2013; Kagaya et al, 2021; Kagaya et al, 2022). Consequently, performing free flap transfer with preservation of the venous arterialization was advantageous when considering the hemodynamics of the bypass graft.…”

Section: Discussionmentioning

confidence: 99%

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Two stages of salvaging an extensively necrotic foot with chronic limb‐threatening ischemia by arterialization of great saphenous vein and free latissimus dorsi musculocutaneous flap transfer for wound coverage with the arterialized vein as the recipient vessel: A case report

Kagaya

Ohura

Miyamoto³

et al. 2022

Microsurgery

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Patients with chronic limb‐threatening ischemia (CLTI) without other options for adequate arterial revascularization could undergo deep (or distal) venous arterialization for limb salvage. Additionally, patients with extensive foot wound with CLTI sometimes require free flap transfer for limb salvage. We herein report a case of successful reconstructive limb‐salvage surgery for an extensively necrotic foot with CLTI, using a two‐stage operation involving venous arterialization using foot‐perforating veins and subsequent free flap transfer (with preservation of the arterialized vein). The patient was a 59‐year‐old man with CLTI. The patient's right foot had dry necrotic tissue after Lisfranc joint amputation. Only one straight‐line to the posterior tibial artery was achieved after endovascular therapies (four times). At the first stage of surgery, an arterial–venous shunt bypass from the superficial femoral artery to the distal great saphenous vein (GSV) (near the foot‐perforating vein) was created. Arterial blood supply reached the necrotic area via the foot venous circulation system. At the second stage of surgery, free latissimus dorsi musculocutaneous flap (8 × 27 cm) transfer with preservation of the arterialized vein was performed. The pedicle artery was anastomosed to the bypass graft (end‐to‐side). The pedicle vein was anastomosed to the proximal stump of the GSV (end‐to‐end). The flap and residual foot survived completely, at a one‐year follow‐up postoperatively. An indocyanine green bypass‐through angiography revealed the angiosome through the venous arterialization bypass graft, which included the flap; entire forefoot; and partial regions of the midfoot and heel. This two‐stage operation might be considered a useful option for limb‐salvage and complete wound‐healing in patients with severe non‐healing wound with CLTI. The two methods could compensate and overcome the problems of either method: incomplete wound‐healing after venous arterialization, and the absence of a recipient artery for free flap transfer.

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Section: Discussionmentioning

confidence: 99%