Percutaneous Transluminal Ballooning Angioplasty for Flap Salvage in a Complex Lower Extremity Reconstruction

Abstract

The treatment of lower extremity trauma with extensive soft tissue defects requires a multidisciplinary approach. Following precise bone fixation, appropriate soft tissue reconstruction is a major requisite. We present a case of a severe lower extremity injury caused by an excavator bucket that fell on the patient's foot, which was reconstructed with multiple perforator flaps after concise bone fixation. During the treatment, we repeatedly experienced threatened flaps, which could not be recovered with emergent re-explorations. Although vascular occlusion after a free flap surgery may be rare, it poses a major challenge. It necessitates urgent re-exploration, but there are logistical challenges with providing sufficient resources for endovascular revascularization. We attempted an immediate postoperative angioplasty after the failure of surgical re-exploration as a salvage option and achieved successful flap survival. As the flap completely survived without complications, the patient could walk, with bearing his full weight without the use of any orthosis. Despite the development of new techniques for flap revision, which have increased the possibility of limb salvage, immediate postoperative endovascular revascularization can be considered as a salvage option in cases of a compromised flap.

Fig. 1.

Preoperative radiographic image showing 1^st–4^th metatarsal bone fractures with dislocation of Lisfranc, intertarsal, and transverse tarsal joints.

Fig. 2.

Photograph displaying a 6 cm ×14 cm defect in the foot dorsum and exposure of the fixator with the previous thoracodorsal artery perforator free flap at the medial malleolus.

Fig. 3.

Angiographic image showing occlusion of the distal anterior tibial artery.

Fig. 4.

Postoperative photograph of the patient’s leg 7 months after surgery, showing a completely survived flap without complications.