What is the impact of infrapopliteal endovascular intervention on free flap survival in diabetic foot reconstruction?

Abstract

Background: The combination of endovascular intervention and microvascular free flap transfer has been effectively used for chronic ischemic wounds of lower limb. The aim of this study was to determine the influence of angioplasty on free flap survival in diabetic foot ulcer reconstruction.

Methods: A retrospective research was conducted for 46 diabetic patients with chronic ulcer of the foot. All patients underwent free flap reconstruction because of their non-healing wound with tendon or bone exposure. Patient's demography, clinical data related to vascular status, vascular intervention, and free flap transfer procedure were collected. Flap survival rate was compared between the group with severe arterial stenosis group and non-severe stenosis group. It was also compared among groups with different revascularization results.

Results: The average age of patients was 56.2 ± 10.8 years. There were 14 (30.4%) men and 32 (69.6%) women. Of 46 patients, 23 (50%) had severe infrapopliteal arterial stenosis. All 23 patients underwent endovascular intervention. Their final results of the pedal arch were type 1 in 13 patients, type 2A in 7 patients, type 2B in 2 patients, and type 3 in 1 patient. Total flap necrosis was found in 5 (10.9%) cases, marginal necrosis in 4 (8.7%) cases, and wound dehiscence in 4 (8.7%) cases. There was no significant difference in flap loss between severe arterial stenosis patients and non-severe arterial stenosis patients. In the severe arterial stenosis group, after endovascular intervention, patients with type 1 of pedal arch had a significantly lower rate of total flap necrosis than others. There was no association between the use of revascularized recipient artery and flap survival.

Conclusions: Our study revealed that the quality of pedal arch was crucial for free flap survival. Thus, PTA should aim to re-establish a complete pedal arch to increase wound healing rate and flap success.

Keywords: Diabetic foot; Endovascular intervention; Free flap; Percutaneous transluminal Angioplasty; Peripheral arterial disease.

Fig. 1

a A chronic wound of dorsal foot. b, c Anterior tibial artery was totally occluded, and pre-operative angiography indicated the type 2B of the pedal arch. d Anterior tibial artery was successfully revascularized and the foot was supplied by both dorsal pedis artery and plantar artery. e ALT free flap. f One day after operation. g Four months post-operation

Fig. 2

a Soft-tissue defect with 5th metatarsal bone exposure. b Angiography showing total occlusion of posterior tibial artery and plantar artery. c Complete pedal arch (type 1) was seen post-angioplasty. d A 13 × 9 cm ALT flap was performed. e Two days post-operation. f Four-year follow-up