Lateral Plantar Angioplasty and Reverse Sural Flap Reconstruction for Complex Heel Limb Salvage

Diabetic foot ulcers complicated by peripheral arterial disease are associated with poor wound healing and an increased risk of amputation. Heel wounds are particularly difficult to reconstruct because of their weight-bearing function and limited soft-tissue coverage. While revascularization is commonly performed for critical limb ischemia, limited evidence guides its use prior to reconstructive surgery in patients with preserved in-line arterial flow. A 58-year-old woman with insulin-dependent diabetes mellitus presented with a chronic infected plantar heel ulcer with exposed calcaneus and suspected osteomyelitis. Vascular imaging demonstrated preserved in-line flow to the foot through the dorsalis pedis artery but chronic occlusion of the distal posterior tibial and plantar arteries. Given the planned reverse sural flap reconstruction and the high perfusion demands of a weight-bearing plantar flap, a multidisciplinary team performed targeted plantar angioplasty despite adequate baseline limb perfusion. Endovascular intervention of the superficial femoral, posterior tibial, and plantar arteries improved distal plantar perfusion without complications, allowing the patient to proceed with planned soft-tissue reconstruction. This case highlights a reconstructive approach in which revascularization optimized flap perfusion rather than restored limb viability. In selected patients with complex plantar heel defects, angiosome-directed revascularization may deliver additional perfusion to support reconstructive success when flap survival is the primary goal. In carefully selected patients, targeted plantar revascularization may be considered before complex heel reconstruction, emphasizing the importance of multidisciplinary planning in limb salvage.