Algorithmic recipient vessel selection for vessel-depleted lower limbs

Lower limb reconstruction is a complex challenge that requires careful selection of recipient vessels to achieve optimal outcomes. We aimed to develop an algorithm for selecting recipient vessels based on defect location, size, composition, and lower limb vasculature.

We retrospectively reviewed 518 consecutive lower limb free flap reconstructions from 1983 to 2022. Using our hospital database, we developed an algorithm to identify suitable recipient vessels and matched them with appropriate reconstructive techniques.

The algorithm classifies patients into four groups based on vascular availability. Group I included 419 patients with intact vessels who underwent direct anastomosis to a suitable flap. Group II comprised 25 patients with no accessible vessels below the medial sural artery. These patients were reconstructed with a free flap using a long vascular pedicle (anterolateral thigh flap, latissimus dorsi, and fibular flap), anastomosed to the medial sural artery. Twenty-one patients in Group III had accessible vessels only in the thigh and underwent reconstruction with a vein loop or two free flaps to reach the defect. A radial forearm flap served as a bridge flap, connecting an additional flap to cover the defect. Fifty-three patients in Group IV had no vessels available in the lower limb, but the foot remained perfused and sensate. This group underwent a two-stage procedure: first, a radial forearm bridge flap was connected to a recipient vessel in the healthy limb; after maturation, a second free flap was anastomosed to the bridge flap to cover the defect.

Our database shows that this algorithm offers a thorough and reproducible method for selecting recipient vessels in microsurgical lower limb reconstruction.