Successful limb salvage through staged bypass combined with free gracilis muscle transfer for critical limb ischemia with osteomyelitis after failed endovascular therapy

Abstract

BackgroundCritical limb ischemia with osteomyelitis is so difficult to treat that even appropriate revascularization and wound therapy cannot achieve limb salvage because of uncontrollable infection. It is still difficult to judge the possibility of limb salvage before revascularization.Case presentationA 73-year-old male complained of a small ulcer on his left toe, which was treated with multiple endovascular therapy. After failed endovascular therapy, he suffered extensive tissue loss with tibial osteomyelitis. We carried out staged surgery that was composed of dual bypass to the sural artery and posterior tibial artery. After intensive debridement and wound care, insertion of a subsequent free gracilis muscle flap to cover the exposed tibial bone was performed, achieving functional limb salvage.ConclusionEven in the threatened limb with extensive tissue loss and osteomyelitis, intensive and multidisciplinary treatment with staged revascularization, muscle transfer, and appropriate wound care achieved functional limb salvage.

Collateral artery bypass in the infrapopliteal segment

“… 11 This type of bypass grafting is quite exceptional and should only be used as the last resort when other conventional bypass techniques are impossible. 12 After understanding the preferred criteria and disadvantages, the collateral artery may be an option for bypass targets even if it develops in the distal infrapopliteal segment. Thus, candidates for this procedure should be limited to patients who have collateral arteries that meet certain anatomical conditions and whose collateral artery is patent as a runoff artery in the foot segment.…”