The possibility of free tissue transfer as a nutrient flap for critical ischemic foot: A case report

Abstract

Microsurgical procedure of free tissue transfer in critical limb ischemia patients with large ulceration has already been established. The nutrient flap concept was that transferred tissue functioned not only to cover the skin defect but also as a supplementary blood supply to the ischemic lower leg. This report showed the justification for this concept, which was rarely discussed. A 58-year-old male patient with progressive forefoot gangrene caused by arteriosclerosis obliterans was presented. The distal bypass procedure was performed as revascularization surgery, and a latissimus dorsi (LD) myocutaneous flap was transplanted to cover ulceration. The arterial pedicle of the flap was anastomosed to the vein graft in an end-to-end manner, and the venous pedicle was anastomosed to the posterior tibialis vein in an end-to-end manner. Bypass graft blood flow went straight to the LD flap only. The postoperative course was uneventful. The free flap and right foot survived successfully and the patient was ambulatory with no recurrence of ulceration wearing order-made shoes more than three years after transplantation. Vessel-selective angiography was performed two months after surgery. An angiographic catheter was inserted into the bypass graft, which ran straight through the flap nutrient artery. The results obtained showed that not only the transferred flap area, but also the remaining original foot soft tissue (including the sole and heel) was clearly visualized radiologically only through the flap nutrient vessel. This findings of the angiography appear to provide direct evidence for the nutrient flap concept.

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

“…Previous reports regarding the nutrient flap had presented only still images of blood flow, without showing dynamic perfusion from the flap into the surrounding tissue. 1 , 2 , 3 , 4 , 5 In the present case, we were able to demonstrate dynamic blood migration from the flap to the adjacent ischemic tissue ( Supplementary Video ), which we considered evidence of a nutrient flap. However, we found that the method has a substantial risk of causing thrombotic occlusion of the bypass graft owing to the limited runoff route for the blood flow.…”

“…The concept of a “nutrient flap,” in which ischemic tissue is nourished by a transferred well-perfused flap, has been advocated for use since the early days of free flap procedures. 1 , 2 , 3 , 4 , 5 Nutrient flap transfer has been applied, especially for the treatment of no-option chronic limb-threatening ischemia (CLTI). However, even among the reported cases in which a nutrient flap was successfully applied, no study has reported the detection of the dynamic flow of nutritional vascular formation over the flap edge.…”

A Retrospective Case Series on Free Flap Reconstruction for Ischemic Diabetic Foot: The Nutrient Flap Further Explained

“…This result shows that patients who underwent free flap surgery were able to not only sustain the increased oxygen tension level after percutaneous transluminal angioplasty but also augment it, further supporting the idea of the nutrient flap. 30,31,58 Although the time point is unclear as to when the transcutaneous partial pressure of oxygen level starts to drop after percutaneous transluminal angioplasty in the non–free flap group, the mean level of 32.9 mmHg at 6 months shows that oxygen level after percutaneous transluminal angioplasty was not sustained, despite the initial improvement, and gradually declined after the angioplasty. Therefore, in the free flap group, one can assume that the tissue oxygen level will start to decline on the surrounding tissue as well.…”

Free Flap Salvage in the Ischemic Foot: A Case Report

“…1 The free flap in such cases serves as a nutrient flap, which nourishes the ischemic area, promotes angioneogenesis, and provides soft tissue coverage. 5…”