Advanced leg salvage of the critically ischemic leg with major tissue loss by vascular and plastic surgeon teamwork: Long-term outcome

Abstract

Objective: To assess long-term outcome and prognostic factors for extreme surgery by vascular and plastic surgical teamwork for leg salvage in patients with critically ischemic large tissue defects.

Summary background data: Combined vascular reconstruction and microvascular free-flap transfer has been used to improve distal perfusion and cover large tissue defects caused by the critical limb ischemia (CLI) in few dedicated centers during the past 15 years. Comorbidities compromise the results of these demanding operations, and it is unclear how far this mode of treatment should be extended.

Methods: During 1989 to 2003, altogether 2157 vascular or endovascular revascularizations for CLI manifested as tissue lesions were performed. These included 81 revascularizations combined with microvascular free flap transfers in 79 patients (37-85 years). All the patients were candidates for major amputation. The patients were followed up at least 2 years or to death (mean follow-up, 62 months; SD, +/-34 months).

Results: One- and 5-year leg salvage rates were 73% and 66%, survival rates 91% and 63%, and amputation-free survival rates of 70% and 41%, respectively. Male gender and American Society of Anesthesiologists score 4 were associated with an increased risk of death, whereas the involvement of the heel mostly with calcaneal osteomyelitis and a large size of defect predicted major amputation.

Conclusions: A combined vascular reconstruction and free-flap transfer offers an option for advanced limb salvage in a selected group of patients with CLI and a major tissue defect. Poor general condition, the involvement of the heel, and a large defect would indicate an amputation over extreme attempts for limb salvage.

FIGURE 1. A decision tree for the treatment of critical ischemia and tissue loss of the leg in Helsinki University Central Hospital 1989–2003.

FIGURE 2. A, Ulceration of the MT amputation stump. B, DSA showing poor run off distal to popliteal artery: sequential vein bypass was made from common femoral artery to anterior tibial artery and further to dorsalis pedis artery. C, The middle anastomosis under construction. D, Fasciocutaneous radial forearm flap contouring the stump, pedicle area covered with split thickness skin graft to avoid tension.

FIGURE 3. A, Large forefoot defect after III and IV ray amputation in a 44-year-old uremic patient. B, Plantar view after amputation of the second toe. C, Latissimus dorsi free flap transfer after femorotibial bypass. D, Outcome at 2 months.

FIGURE 4. Amputation-free survival (A) and leg salvage (B) after combined vascular reconstruction and microvascular free flap transfer: Kaplan-Meier analysis. Numbers at risk are shown in the figure.

FIGURE 5. Yearly distribution of combined vascular reconstructions and microvascular free flap transfers in Helsinki University Central Hospital (1989–2003).

FIGURE 6. Cross-sectional analysis on the level of ambulation at 2 years after combined vascular reconstruction and free tissue transfer.