Atherosclerosis of the lower extremity and free-tissue reconstruction for limb salvage

Atherosclerosis of the lower extremity frequently leads to limb-threatening ischemic soft-tissue wounds. Over the past 44 months, 30 selected patients with arterial disease documented by angiography were treated with combined vascular reconstruction and free-tissue transfer for limb salvage. Soft-tissue defects occurred on the plantar and dorsal surfaces of the foot and distal tibia with significant bone, tendon, or joint exposure. Thirteen patients had osteomyelitis. Eighteen patients underwent simultaneous soft-tissue and vascular reconstruction, while 12 patients underwent delayed soft-tissue reconstruction. The free-flap tissues included the rectus abdominis flap in 13, the latissimus dorsi flap in 7, the radial forearm flap in 5, the scapular flap in 3, and the omentum flap in 2. Autogenous venous bypass was performed to the popliteal segment in 6 patients and the infrapopliteal arteries in 18. Five patients had inadequate outflow for complete vascular reconstruction and were treated with proximal vein grafts directed into the free flap. Twenty-two patients (73 percent) had successful free-tissue transfer and bypass graft patency and were independent ambulators over the mean follow-up period of 22 months. Of the 8 unsuccessful reconstructions, 3 patients had early free-flap and graft failure. Five patients developed new areas of ischemic disease despite graft and flap patency. All 8 patients were treated with amputation; 7 never regained ambulation. The combined application of vascular and free-flap soft-tissue reconstruction for the threatened ischemic lower extremity has produced excellent functional results in the majority of our patients.