Use of revascularized artery as a recipient in microvascular reconstruction of the lower leg: An analysis of 62 consecutive free flap transfers

Overcoming severe calcified lower extremity artery in lower limb salvage operation by using the Fogarty catheter and vein graft

BACKGROUND

With severe vascular calcifications, vascular clamp application and utilizing the vessel for free flap recipient vessel becomes impossible. These obstacles can be overcome with the Fogarty catheter and vein graft.

PATIENTS AND METHODS

When unclampable artery was encountered intraoperatively, a vein graft was used to make a clampable recipient site for six diabetic foot patients (ages from 42 to 80). The end of the Fogarty catheter was inserted into the proximal end of the vein graft and the transected calcified vessel in sequence, and the balloon of the catheter was used as an intraluminal tourniquet. The remaining end of the vein graft was connected to the distal vessel with a vascular clamp.

RESULTS

Five short vein graft revascularization for segmental arterial occlusion, one long vein graft for recipient artery elongation was done (lengths from 2 to 13.8 cm). Three delayed, and two immediate anterolateral thigh flaps (sizes from 15 to 150 cm² ) were performed, and one patient received vein graft revascularization surgery only. Postoperative vascular sonography of all six patients showed well-maintained patency. Minor flap marginal disruption occurred at two patients but healed with conservative care. Postoperative follow-up was done for 1-18 months (average 7.17). Limb salvage was achieved for five patients and all five free flaps survived. However, for one patient, arterial restenosis at popliteal artery a month later lead to major amputation.

CONCLUSION

Using a Fogarty catheter and a vein graft may obtain perfect hemostasis during micro-anastomosis and achieve successful microvascular reconstruction in patients with severely calcified vessels.

Short- and Long-Term Outcomes following Severe Traumatic Lower Extremity Reconstruction: The Value of an Orthoplastic Limb Salvage Center to Racially Underserved Communities

BACKGROUND

Previous studies have demonstrated that nonwhite race and disadvantaged socioeconomic status negatively impact outcomes following lower extremity reconstruction. The authors sought to characterize differences in outcomes between racial groups in patients necessitating traumatic lower extremity reconstruction at an orthoplastic limb salvage center.

METHODS

A retrospective review between 2002 and 2019 was conducted of patients who underwent free flap lower extremity reconstruction at an orthoplastic limb salvage center. Patient demographics were identified, and permanent addresses were used to collect census data. Short-term complications and long-term functional status were recorded.

RESULTS

One hundred seventy-three patients underwent lower extremity reconstruction and met inclusion criteria. Among all three groups, African American patients were more likely to be single (80 percent African American versus 49 percent Caucasian and 29.4 percent other; p < 0.05) and had significantly lower rates of private insurance compared with Caucasian patients (25 percent versus 56.7 percent; p < 0.05). African American patients demonstrated no significant differences in total flap failure (4.9 percent versus 8 percent and 5.6 percent; p = 0.794), reoperations (10 percent versus 5.8 percent and 16.7 percent; p = 0.259), and number of readmissions (2.4 versus 2.0 and 2.1; p = 0.624). Chronic pain management (53.3 percent versus 44.2 percent and 50 percent; p = 0.82), full weight-bearing status (84.2 percent versus 92.7 percent and 100 percent; p = 0.507), and ambulation status (92.7 percent versus 100 percent and 100 percent; p = 0.352) were similar among groups.

CONCLUSIONS

Outcomes are equivalent between racial groups presenting to an orthoplastic limb salvage center for lower extremity reconstruction. The postoperative rehabilitation strategies, follow-up, and overall support that an orthoplastic limb salvage center ensures may lessen the impact of socioeconomic disparities in traumatic lower extremity reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

What is the impact of infrapopliteal endovascular intervention on free flap survival in diabetic foot reconstruction?

Background

The combination of endovascular intervention and microvascular free flap transfer has been effectively used for chronic ischemic wounds of lower limb. The aim of this study was to determine the influence of angioplasty on free flap survival in diabetic foot ulcer reconstruction.

Methods

A retrospective research was conducted for 46 diabetic patients with chronic ulcer of the foot. All patients underwent free flap reconstruction because of their non-healing wound with tendon or bone exposure. Patient’s demography, clinical data related to vascular status, vascular intervention, and free flap transfer procedure were collected. Flap survival rate was compared between the group with severe arterial stenosis group and non-severe stenosis group. It was also compared among groups with different revascularization results.

Results

The average age of patients was 56.2 ± 10.8 years. There were 14 (30.4%) men and 32 (69.6%) women. Of 46 patients, 23 (50%) had severe infrapopliteal arterial stenosis. All 23 patients underwent endovascular intervention. Their final results of the pedal arch were type 1 in 13 patients, type 2A in 7 patients, type 2B in 2 patients, and type 3 in 1 patient. Total flap necrosis was found in 5 (10.9%) cases, marginal necrosis in 4 (8.7%) cases, and wound dehiscence in 4 (8.7%) cases. There was no significant difference in flap loss between severe arterial stenosis patients and non-severe arterial stenosis patients. In the severe arterial stenosis group, after endovascular intervention, patients with type 1 of pedal arch had a significantly lower rate of total flap necrosis than others. There was no association between the use of revascularized recipient artery and flap survival.

Conclusions

Our study revealed that the quality of pedal arch was crucial for free flap survival. Thus, PTA should aim to re-establish a complete pedal arch to increase wound healing rate and flap success.

Influence of time interval between endovascular intervention and free flap transfer on flap outcomes in critical limb-threatening ischemia: A retrospective analysis of 64 consecutive cases

BACKGROUND

Arterial revascularization and free flap reconstruction is safe and effective for limb salvage in patients with critical limb-threatening ischemia (CLTI). This study aimed to determine whether reconstruction outcomes were affected by the time interval between endovascular treatment and free flap transfer in lower extremity reconstruction for critical limb ischemia.

METHODS

Patients who underwent endovascular intervention and subsequent free flap reconstruction with >6 months of follow-up were reviewed. Those with wounds with oncological and traumatic etiologies were excluded. Patients' demographics, risk factors, details of microsurgical procedures, details of endovascular intervention, and flap outcomes were collected.

RESULTS

Overall, 64 consecutive patients (M:F = 50:14 and mean age, 57.3 [range, 29-82] years) were evaluated between November 2011 and October 2019. Angioplasty failed in three patients. For soft-tissue reconstruction, anterolateral free flaps were used most frequently (n = 54 and 84.4%). Flap-related complications developed in 12 cases, of which five cases included total flap necrosis. The interval between endovascular intervention and free flap transfer was not associated with flap loss in multivariate regression analysis. Patients with kidney transplants and higher serum creatinine were associated with total flap necrosis. Advanced age, failed angioplasty, and perfusion status of the pedal arch were associated with major flap complications.

CONCLUSION

The time interval between endovascular treatment and free flap reconstruction was not associated with flap complications. Free flap reconstruction of chronic wounds caused by CLTI can be safely planned regardless of the time duration from preoperative angioplasty.

Management of Post-Traumatic Osteomyelitis in the Lower Limb: Current State of the Art

Osteomyelitis (OM) of the lower limb represents a large unmet global healthcare burden. It often arises from a contiguous focus of infection and is a recognized complication of open fractures or their surgical treatment, arthroplasty, and diabetic foot ulcers. Historically, this debilitating condition is associated with high rates of recurrence and secondary amputation. However, excellent long-term outcomes are now achieved by adopting a multidisciplinary approach with meticulous surgical debridement, skeletal and soft tissue reconstruction, and tailored antimicrobial treatment. This review focuses on the modern evidence-based management of post-traumatic OM in the lower limb from a reconstructive plastic surgery perspective, highlighting the latest developments and areas of controversy.