Free Tissue Transfer in Patients with Severe Peripheral Arterial Disease: Functional Outcome in Reconstruction of Chronic Lower Extremity Defects

Abstract

Chronic wounds of the lower extremity are difficult to treat, especially in patients with peripheral arterial disease (PAD). This patient population frequently suffers from multiple comorbidities, which further impairs wound healing. Local flaps are often not available, or are insufficient to cover these defects, and limbs are frequently amputated, although they could possibly be salvaged by free tissue transplantation. Although there is a growing evidence that free tissue transfer may be feasible in these patients with otherwise doomed extremities, previous studies have mostly focused on short-term flap survival, but not long-term ambulatory status and independence. Therefore, we investigated the long-term results of limb salvage, ambulatory status, and social independence in patients with PAD who underwent free tissue transfer for chronic wounds of the lower extremities.In this study we retrospectively reviewed 38 patients who underwent free tissue transfer because of nontraumatic, chronic wounds of the lower extremities at our institution. All patients suffered from a nontraumatic occlusion of at least one major lower leg artery verified by angiography. After a mean time period of 34 months we assessed flap survival and limb preservation as well as pre- and postoperative ambulatory status and social independence. A subgroup of 14 patients with a "single-vessel-leg" was evaluated separately.It was observed that anterolateral thigh and latissimus dorsi musculocutaneous flaps were most often used to cover the defects. Overall 29 out of the 38 flaps healed completely (9 flap failures) and 34 extremities were salvaged, including 12 out of 14 single-vessel-legs. One patient had to be amputated despite a vital free flap because of persistent calcaneal osteomyelitis. After failure of free tissue transfer, six extremities could still be salvaged by secondary procedures (two secondary free flaps, two local flaps, and two skin grafts). Total 22 out of 34 patients with salvaged limbs maintained or improved their ambulatory status. In the amputee group, two patients remained on their preoperative level of mobility, while two declined. All patients with amputated limbs required assistance in activities of daily living while this was only true for 4 out of the 34 remaining patients.It was concluded that free tissue transfer is a valid option for salvaging lower extremities in patients with PAD. Long-term limb salvage can be achieved in a high percentage of cases, which allows the patients to ambulate freely and remain socially independent.

Flap Decisions and Options in Soft Tissue Coverage of the Lower Limb

“…It has been reported that, when offered, a high percentage of patients (93%) would prefer a limb salvage procedure in the traumatic scenario to avoid undergoing amputation [ 6 ], and as an option in the chronic wound, reconstruction provides a chance for the patient to remain socially independent and maintain or improve their ambulatory status [ 7 ].…”

Anterolateral Thigh Free Flap to Cover Diabetic Foot Defect by Using Reverse Flow of Severely Calcified Dorsalis Pedis Artery

“…Chronic hyperglycemia with oxidative stress causes atherosclerosis and vascular calcification, especially in the infragenicular arteries of the lower extremity [2]. With the development of diffuse arterial occlusion of the tibial arteries, the distal part of the limb is prone to intractable limb ischemia due to unreliable blood supply and the propensity for soft tissue and bone infections [2,4].…”

“…Since an amputation is an enormous burden for diabetes patients, the optimal selection of a surgical procedure and its skillful execution are imperative for possible foot salvage [3]. Presently, with advancements in microsurgical techniques, free tissue transfer has been frequently performed to restore a severely injured diabetic foot associated with osteomyelitis [4]. This article presents the successful reconstruction of a diabetic foot using a reverse flow of the severely calcified dorsalis pedis artery (DPA) as the recipient vessel.…”

Effect of Atherosclerosis on the Lateral Circumflex Femoral Artery and Its Descending Branch: Comparative Study to Nonatherosclerotic Risk

“…Although, the free ALT in severe atherosclerosis is not contraindicated and the successful microsurgical ALT for limb salvage in diabetic foot ulcer was demonstrated, 21 – 23 the failure rate increased in the smoking and multiple atherosclerotic risk factor groups. 24 The clinical significance of the differences in arterial diameter between atherosclerosis and nonatherosclerosis is still inconclusive, but the effects of atherosclerotic risk factors caused stenosis of the dLCFA, LCFA, and DFA occurred in varying degrees.…”