[New trends in limb salvage. Vascularized flaps]

Femoro-distal bypasses are not always feasible or indicated in patients presenting with "critical" chronic ischemia. The results of nutrient flaps carried out over a 2-year period are analyzed.

12 patients had extensive gangrene compromising limb salvage (heel, dorsal or lateral aspect of foot or ankle at high risk of tendon or joint sepsis). Coverage of tissue loss was provided by a latissimus dorsi flap in 8 patients, a radial artery free flap in 1 patient, a supra-malleolar flap in 3 patients.

The hospital mortality rate was 8.3%. The cumulative patency and limb salvage rates are respectively 58% and 67% at 6 months, 44% and 67% at 12 months.

The challenge of inframalleolar reconstruction in patients presenting with critical ischemia is not always amenable to surgical revascularization to the foot, due to the lack of a suitable artery for bypass implantation or due to the lack of run-off, when arteriosclerosis of the plantar arch, or when distal embolisms are present. Some patients present with extensive gangrene, and in most of cases infection of the foot, and carry a high risk of arthritis: they are not likely to heal properly if surgical bypass alone to a foot artery is done. Bypass surgery is not indicated in diabetic patients with extensive foot infection, in whom no significant macroangiopathy is present. These 3 situations are a good indication for flaps, in order to cover the tissue loss, to fight the infection, and to provide a vascular supply to the foot. When conventional therapies cannot face critical ischemia, nutrient flaps can provide a fair limb salvage rate.