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

The role of flaps in preventing lower extremity amputations

The increasing prevalence of chronic limb-threatening ischemia and diabetes mellitus has led to a surge in lower extremity amputations, driven by the combination of peripheral arterial disease and extensive wounds. Although revascularization often addresses ischemia, severe wounds pose a significant risk of amputation. Flaps, which involve the transfer of vascularized tissue, can provide immediate closure of complex wounds, particularly those involving bone or tendon exposure, where skin grafts are insufficient. Flap reconstruction of wounds can prevent amputation in cases when revascularization alone would not, but these complex efforts require close collaboration between vascular and plastic surgeons. Despite their potential to prevent amputations, flaps are underused in vascular surgery due to limited availability and expertise, particularly in complex cases involving diabetes and peripheral vascular disease. There are also socioeconomic and reimbursement challenges that limit interest on the part of plastic surgeons. This article explores the principles, techniques, and challenges of flap reconstruction in lower extremity limb salvage, emphasizing the need for multidisciplinary care.

[Revascularization Prior to Defect Reconstruction of the Lower Limb - Essential Cooperation between Plastic and Vascular Surgery]

Treatment of complex ischemic lower leg defects with exposure of deep anatomic structures represents a considerable challenge to involved specialties. In selected patients, limb salvage can be achieved as an alternative to major amputation by means of a combined approach including arterial reconstruction and subsequent free flap transfer. Arterial reconstruction can be performed either by endovascular or open surgical treatment (bypass reconstruction or implantation of an arteriovenous loop) preliminary to defect reconstruction using microsurgical free flap transplantation. Whereas the aim of the arterial reconstruction comprises the establishment of sufficient perfusion and creation of adequate target vessels for the free flap transfer, the selection of the appropriate flap entity depends on the extent of the wound as wells as on the presence of osteomyelitis. Arterial reconstruction and defect reconstruction can be performed as one-stage or two-stage procedure and has become an established and feasible treatment approach in centers. Evaluation of microperfusion by means of indocyanine green can further increase safety and feasibility of this method. Against this background, combined arterial reconstruction and subsequent free flap transfer provides excellent results in terms of amputation free survival and postoperative mobility. Essential is however an individualized decision making in consideration of patient selection and possible contraindications. This approach may be evaluated in mobile patients with complex wounds prior to major amputation.

Combined Revascularization and Free Flap Reconstruction for Chronic Limb-Threatening Ischemia: A Systematic Review and Meta-Analysis

BACKGROUND

 Combined revascularization and free flap reconstruction is one treatment method for chronic limb-threatening ischemia (CLTI) with complex wounds. The purpose of this systematic review and meta-analysis was to investigate the characteristics of this combined procedure and to assess postoperative outcomes.

METHODS

 A systematic search was performed across PubMed, Scopus, and the Web of Science for studies between January 2000 and February 2022. A random-effects meta-analysis for postoperative outcome was conducted.

RESULTS

 Fifteen articles encompassing 1,176 patients with 1,194 free flaps were ultimately included in the qualitative and quantitative assessment. Our meta-analysis showed the following complication rates for short-term postoperative outcomes: 37% (95% confidence interval [CI], 18-53%; I 2 = 74%) for reoperation, 13% (95% CI, 2-24%; I 2 = 0%) for vascular thrombosis, 9% (95% CI, 0-17%; I 2 = 0%) for total flap failure, 8% (95% CI, 0-17%; I 2 = 0%) for partial flap failure, 4% (95% CI, 0-10%; I 2 = 0%) for amputation, and 3% (95% CI, 0-9%; I 2 = 0%) for 30-day mortality. The 1-, 3-, and 5-year limb salvage rates were 86% (95% CI, 78-92%), 81% (95% CI, 68-88%), and 71% (95% CI, 53-83%), respectively. The 1-, 3-, and 5-year patient survival rates were 93% (95% CI, 90-96%), 92% (95% CI, 77-97%), and 75% (95% CI, 50-88%), respectively.

CONCLUSION

 Combined revascularization and free flap reconstruction for CLTI with complex wounds was clearly effective for the long-term outcomes. However, this combined procedure should be considered on the assumption that the reoperation rate is high and that flap-related complications rate may be higher than lower extremity reconstruction of other etiologies.