Combined vascular reconstruction and free flap transfer in diabetic arterial disease

Gangrenous lesions of the foot or lower leg due to severe diabetic arterial disease resulting in extensive soft tissue defects with exposed bones or tendons often result, even after successful revascularisation, in staged or primary amputation. We present our experience with 45 such patients treated with combined arterial reconstruction and free tissue transfer for limb-salvage. All presented with peripheral vascular disease of diabetic origin, and extensive gangrenous lesions that could not be treated by simple wound closure or skin-grafting without major amputation. A total of 53 arterial reconstructions and 47 free-flap transfers were performed. In the majority of patients, the distal anastomosis was on a pedal or tibial vessel. These bypass grafts or a native revascularized artery served as the inflow tract for the free flap which was anastomosed using microsurgical techniques. Venous anastomoses were preferentially performed on the deep venous system. Donor muscles were Musculus rectus abdominis (n=37), Musculus latissimus dorsi (n=5), Musculus serratus anterior (n=3), and a perforator flap (n=2) tailored to the size of the defect and covered with a split thickness graft (STG). The operation was set up as a combined procedure in 39/45 patients, two teams working simultaneously, limiting the mean operative time to 6 h. Early reinterventions had to be performed in 14 patients resulting in five flap losses of which two could be treated with a new free flap transfer and three were amputated. Three other patients died in the postoperative period, leaving us with a total of 39/45 patients leaving the hospital with a full-length limb. Independent ambulation was achieved in 32 of these 39 patients. During late follow-up (mean 26 months) eight bypasses occluded resulting in two amputations and two new vascular reconstructions. Combined survival and limb-salvage rate was 84% after 1 year, 77% after 2 years and 65% after 3 years. The advantages of this combined technique are: (1) it provides immediate soft tissue coverage limiting amputation level and healing time, resulting in early ambulation; (2) it provides extra run-off to the revascularisation, illustrated by a decrease in peripheral resistance, contributing to its patency; (3) the application of healthy, well vascularised tissue limits infection and enhances neovascularisation; (4) a full-length limb is preserved. We believe this combined approach offers a valuable alternative to primary amputation in this group of patients with extensive ischaemic defects.