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Limb-salvage by Femoro-distal Bypass and Free Muscle Flap Transfer
Eur J Vasc Endovasc Surg 27, 635–639 (2004) doi: 10.1016/j.ejvs.2004.02.028, available online at http://www.sciencedirect.com on
Limb-salvage by Femoro-distal Bypass and Free Muscle Flap Transfer M. Czerny,* W. Trubel,2 D. Zimpfer,1 M. Grimm,1 R. Koller,3 W. Hofmann,1 T. Holzenbein,2 P. Polterauer2 and W. Girsch3 Departments of 1Cardiothoracic Surgery, 2Vascular Surgery, and 3Plastic and Reconstructive Surgery, University of Vienna Medical School, Vienna, Austria Objectives. To evaluate the feasibility and long-term outcome of distal arterial reconstruction combined with free muscle flap transfer for patients who would otherwise have undergone major amputation. Methods. Between 1996 and 2001, 27 reconstructions using autologous vein were performed in 25 patients. Seventeen of these patients had diabetes mellitus. Gracilis, rectus abdominis and latissimus dorsi muscles were used as free flaps, covered with split-thickness skin grafts. Results. Eighty-five percent of patients had a patent graft and viable muscle flap after 1-month. Mean follow-up was 51 months (4– 72 months). At the time of follow-up 77% of reconstructions were patent and 70% of patients regained full functional capacity of their lower extremities. Conclusion. Limb-salvage by distal arterial reconstruction and free muscle flap transfer, is feasible with low mortality and morbidity and provides excellent long-term results with regard to graft patency and functional status. Key Words: Distal arterial reconstruction; Muscle flap transfer.
Introduction Distal bypass is an established method for limbsalvage in peripheral arterial occlusive disease (PAOD), providing excellent long term patency as well as functional limb status. However, in patients presenting with extensive gangrene even successful distal revascularization will not be sufficient for limb salvage. Arterial reconstruction may also be limited by an area of tissue necrosis adjacent to a planned anastomotic site, thereby preventing primary closure of the wound. Standard plastic surgical methods such as split-thickness skin grafts or pedicle skin flaps are often insufficient to gain wound closure in this particular subset of patients with severe PAOD in combination with tissue loss. Free muscle flap transfer is an excellent method to provide wound coverage and to increase distal outflow thereby reducing peripheral vascular resistance.1,2 Soft tissue or bone defects of variable extent may thereby be covered by autologous material and consecutively limb-salvage can be achieved and a *Corresponding author. Dr M. Czerny, MD, Waehringer Guertel 18-20, A-1090 Vienna, Austria, Europe.
normal functional status of the lower extremity regained.3,4 At present, only few centers provide this combined approach for limb-salvage and therefore the outcome of this approach is poorly documented.1 – 6 The aim of this study was to evaluate feasibility and mid-term outcome of the combined approach of distal arterial reconstruction and free muscle flap transfer in lower extremities that otherwise would have undergone major amputation.
Methods Patients Between January 1996 and December 2000, 25 patients (male 19, 76%; female 6, 24%) were selected for distal revascularization and free flap. Patient information was entered prospectively onto a database. Mean age was 64 years (33 –84 years). Seventeen patients (68%) had diabetes mellitus and of these, 11 were insulindependent. Other comorbidities were chronic renal insufficiency requiring dialysis (4), previous renal transplantation (3), osteomyelitis (3), primarily chronic polyarthritis (1), and thrombangitis obliterans (1). The
1078–5884/060635 + 05 $35.00/0 q 2004 Elsevier Ltd. All rights reserved.
M. Czerny et al.
636
Fig. 1. Tissue defect located at the heel with involvement of calcaneus.
majority of patients (80%) had already undergone previous vascular interventions as distal arterial reconstruction (10), percutaneous transluminal angioplasty (8) and thrombolysis (2). Soft tissue and bone defects were found on four major locations: crural (4), malleolar (4), heel (15), forefoot (4). All patients underwent diagnostic digital subtraction angiography prior to surgery.
Operative methods The surgical approach followed a set protocol. Initially, necrotic tissue was debrided in order to determine the extent of the defect and to eliminate florid infection
[Fig. 1]. One week later, the main procedure was performed by preparation of the anastomotic sites and the venous graft simultaneously to the flap harvest by two operative teams. The type of the flap being used was dependent upon the pedicle length and the size of the coverage required. The vein graft was prepared in order to provide a suitable side branch for anastomosis to the flap artery. If the gap between the side branch and the vascular pedicle was too large, a small venous bypass graft was inserted (Fig. 2). This approach avoided clamping of the bypass graft after establishment of graft flow. In some instances additional jump grafts to the posterior tibial artery were performed, in order to fixate the bypass behind the malleolus, where the anastomosis of bypass and flap was usually
Fig. 2. Intraoperative situs with the muscle vein anastomosed to the adjacent tibial artery as well as the muscle artery anastomosed to a venous jump graft. Eur J Vasc Endovasc Surg Vol 27, June 2004
Distal Bypass and Muscle Flap Transfer
637
Fig. 3. Intraoperative situs after reperfusion and fixation of the muscle flap in a patient with an ulcus located at the ankle.
situated. After reperfusion of the flap, tension was put on the muscle to reestablish the original fiber length and avoid bulkness. The muscle flap was trimmed to the desired size and was covered with split-thickness skin grafts (Fig. 3). In cases where the flap was positioned around the ankle, the ankle was stabilized either using Kirschner wires or an external fixator in order to improve flap incorporation. Follow-up Patients were reviewed daily for the first 10 days and thereafter as required until wound healing was completed. Graft patency was defined as a palpable pulse over the graft and the distal outflow artery or graft flow as detected by a colour-coded duplex scan. Flap viability was proven by oxygen uptake measurements during the first 10 days postoperatively and by inspection thereafter.
Results Intraoperative data
flaps used were rectus abdominis (6) and latissimus dorsi muscle (3). At 1-month, there were no deaths and 85% (23/27) of limbs had a patent graft and a viable flap. In three patients, early failure of the flap required lower leg amputation. In another patient, erosion of the bypass graft led to lower leg amputation. In two patients, partial loss of the free tissue flap made secondary wound closure necessary. Wound healing disturbancies at the flap harvesting site were observed in seven out of 27 procedures. Mean hospital stay was 34 days.
Functional status of the extremity Twenty patients regained full functional capacity of their lower extremities. Patients with defects in areas without weight bearing surfaces were able to walk after a mean duration of 22 days, whereas patients with defects in areas with weight bearing surfaces required a mean duration of 90 days to regain full functional capacity. The final result is shown in Fig. 4. Table 1. Vascular procedures performed
Mean operative time for this combined approach was 5.5 h (4 – 18 h). Twenty-three patients were reconstructed unilaterally, whereas two patients were reconstructed bilaterally. Bypass was performed using autologous vein (Table 1). Free flap transfer was mainly performed with gracilis muscle (18). Other
Vascular procedures performed
No. of procedures
Femoro-popliteal Femoro-crural Femoro-pedal Popliteo-pedal
3 3 4 17
Eur J Vasc Endovasc Surg Vol 27, June 2004
M. Czerny et al.
638
Fig. 4. Final result in a patient having regained full walking capacity.
Late results Twenty-one patients had a mean follow-up of 51 months (4 – 72 months). Twenty patients with 21 reconstructions had a patent graft and a viable flap at the time of follow-up. Therefore patency rate at this time was 77% (Fig. 5). Nineteen patients had full functional capacity of their lower extremities. In one patient, contralateral lower leg amputation was performed during follow-up.
Discussion Our results show that limb-salvage by distal arterial reconstruction and free muscle flap transfer in lower
Fig. 5. Freedom from major adverse events. Eur J Vasc Endovasc Surg Vol 27, June 2004
extremities otherwise destined for amputation, is feasible and provides excellent long-term outcomes. Due to microangiopathy and sensory neuropathy, patients with diabetes are at increased risk of developing tissue and bone necrosis in their lower extremities, than their non-diabetic atherosclerotic counterparts. The main sites at risk are the weightbearing areas. Due to impairment of the immune system, high rates of lower limb infections are also common in diabetics.7,8 As a consequence, a staged surgical approach was employed with initial debridement, followed by the main procedure one week later. Until recently, major amputation was the only option for patients with extensive tissue necrosis in combination with PAOD. Within the last decade, improved microsurgical techniques have enabled
Distal Bypass and Muscle Flap Transfer
effective free muscle transfer to cover soft tissue and bone defects. The concept of distal arterial revascularization and free muscle flap is supported by several case reports and limited series, reporting a primary patency rate between 57 and 100%.9 – 11 Our primary patency rate of 85% is well in line with other recently published series.3 – 6 However, the success of this combined approach seems to depend on careful selection of patients for this procedure. Illig found that the combination of diabetes and renal failure requiring hemodialysis was the strongest predictor of limb loss in patients after distal arterial reconstruction and free muscle flap transfer. We observed similar findings. All patients with early failure had diabetes and required hemodialysis. The size of the defect and consecutively the size of the free muscle flap also affects the success of the procedure. The gracilis muscle flap has the advantage of minimum donor morbidity, can be performed under loco-regional anesthesia and is tolerant of ischemia. Our second choice flap was the rectus abdominis muscle. If a more substantial defect was present a latissimus dorsi muscle flap was used. When using the latissimus dorsi muscle flap, we experienced problems with the blood supply of the mid and distal portions of the muscle, leading to partial flap loss in two and complete flap loss in one patient. Arterial inflow for the flap was obtained from the distal portion of the bypass conduit while venous outflow was by anastomosis to the tibial veins. In our opinion, avoiding calcified small tibial arteries as inflow vessels very much facilitates the whole procedure. To keep the whole procedure as minimally invasive as possible, the majority of operations were carried out under epidural anesthesia. Our mean duration of surgery was 5.5 h, which is well in line with others.3,4 The 4-year patient survival rate was 80% which compares favorably with results after conventional distal arterial revascularization.12 Long-term patency rate was 77%, which is excellent in patients who would otherwise have undergone major amputation. Other series report similar data with long-term patency rates of 57% after 5 years.4 – 6 Seventy percent of patients regained full functional capacity of their extremities. Time to full ambulation was greater in patients with defects in their weight-bearing areas. Previous studies of distal arterial reconstruction and free muscle flap
639
transfer report operative mortality rates between 0 and 10% and long-term ambulation rates of 60– 90%.1,3,13 In conclusion, soft tissue and bone defects in the lower limbs of patients especially with diabetes are a complex entity with a high risk of limb loss. In this situation, limb-salvage by distal arterial reconstruction and free muscle flap transfer is feasible and provides excellent long-term results.
References 1 Cronenwett JL, McDaniel MD, Zwolak RM, Walsh DB, Schneider JR, Reus FW et al. Limb salvage despite extensive tissue loss: free tissue transfer combined with distal revascularization. Arch Surg 1989; 124:609–615. 2 Serletti JM, Deuber MA, Guidera PM, Herres HR, Reading G, Hurrwitz SR et al. Atherosclerosis of the lower extremity and free-tissue reconstruction for limb-salvage. Plast Reconstr Surg 1995; 96:1136 –1144. 3 McCarthy III WJ, Matsumura JS, Fine NA, Dumanian GA, Pearce WH. Combined arterial reconstruction and free tissue transfer for limg-salvage. J Vasc Surg 1999; 29:814–820. 4 Illig K, Moran S, Serletti J, Ouriel K, Orlando G, Smith A et al. Combined free tissue transfer and infrainguinal bypass graft: an alternative to major amputation in selected patients. J Vasc Surg 2001; 33:17 –23. 5 Tukiainen E, Biancari F, Lepa¨ntalo M. Lower limb revascularization and free flap transfer for major ischemic tissue loss. World J Surg 2000; 24:1531–1536. 6 Vermassen FEG, van Landuyt K. Combined vascular reconstruction and free flap transfer in diabetic arterial disease. Diabetes Metab Res Rev 2000; 16(Suppl. 1):S33–S36. 7 Johnson JE. Infections and diabetes. In: Ellenberg M, ed. Diabetes mellitus: theory and practice. New York: McGraw-Hill, 1970: 734. 8 Casey JI. Host defense and infection in diabetes mellitus. In: Ellenberg M, ed. Diabetes mellitus: theory and practice, 3rd ed. New York: Medical Examiniation Publishing Co., 1983: 667. 9 Gooden MA, Gentile AT, Demas CP, Berman SS. Salvage of femoropedal bypass graft complicated by interval gangrene and vein graft blowout using a flow-through radial forearm fasciocutaneous free flap. J Vasc Surg 1997; 26:711–714. 10 May JW, Halls MH, Simon SR. Free microvascular muscle flaps with skin graft reconstruction of extensive defects of the foot: a clinical and gait analysis study. Plast Reconstr Surg 1985; 75: 627–641. 11 Briggs SE, Banis JC, Kaebnick H, Silverberg B, Acland RD. Distal revascularization and microvascular free tissue transfer: an alternative to amputation in ischemic lesions of the lower extremity. J Vasc Surg 1985; 2:806–811. 12 Gupta AK, Girishkumar H. Lower extremity revascularization. J Cardiovasc Surg 1993; 34:229–236. 13 Ciresi KF, Anthony JP, Hoffman WY, Bowersox JC, Reilly LM, Rapp JH. Limb salvage and wound coverage in patients with large ischemic ulcers: a multidisciplinary approach with revascularization and free tissue transfer. J Vasc Surg 1993; 18:648– 655. Accepted 26 February 2004
Eur J Vasc Endovasc Surg Vol 27, June 2004
Limb-salvage by Femoro-distal Bypass and Free Muscle Flap Transfer M. Czerny,* W. Trubel,2 D. Zimpfer,1 M. Grimm,1 R. Koller,3 W. Hofmann,1 T. Holzenbein,2 P. Polterauer2 and W. Girsch3 Departments of 1Cardiothoracic Surgery, 2Vascular Surgery, and 3Plastic and Reconstructive Surgery, University of Vienna Medical School, Vienna, Austria Objectives. To evaluate the feasibility and long-term outcome of distal arterial reconstruction combined with free muscle flap transfer for patients who would otherwise have undergone major amputation. Methods. Between 1996 and 2001, 27 reconstructions using autologous vein were performed in 25 patients. Seventeen of these patients had diabetes mellitus. Gracilis, rectus abdominis and latissimus dorsi muscles were used as free flaps, covered with split-thickness skin grafts. Results. Eighty-five percent of patients had a patent graft and viable muscle flap after 1-month. Mean follow-up was 51 months (4– 72 months). At the time of follow-up 77% of reconstructions were patent and 70% of patients regained full functional capacity of their lower extremities. Conclusion. Limb-salvage by distal arterial reconstruction and free muscle flap transfer, is feasible with low mortality and morbidity and provides excellent long-term results with regard to graft patency and functional status. Key Words: Distal arterial reconstruction; Muscle flap transfer.
Introduction Distal bypass is an established method for limbsalvage in peripheral arterial occlusive disease (PAOD), providing excellent long term patency as well as functional limb status. However, in patients presenting with extensive gangrene even successful distal revascularization will not be sufficient for limb salvage. Arterial reconstruction may also be limited by an area of tissue necrosis adjacent to a planned anastomotic site, thereby preventing primary closure of the wound. Standard plastic surgical methods such as split-thickness skin grafts or pedicle skin flaps are often insufficient to gain wound closure in this particular subset of patients with severe PAOD in combination with tissue loss. Free muscle flap transfer is an excellent method to provide wound coverage and to increase distal outflow thereby reducing peripheral vascular resistance.1,2 Soft tissue or bone defects of variable extent may thereby be covered by autologous material and consecutively limb-salvage can be achieved and a *Corresponding author. Dr M. Czerny, MD, Waehringer Guertel 18-20, A-1090 Vienna, Austria, Europe.
normal functional status of the lower extremity regained.3,4 At present, only few centers provide this combined approach for limb-salvage and therefore the outcome of this approach is poorly documented.1 – 6 The aim of this study was to evaluate feasibility and mid-term outcome of the combined approach of distal arterial reconstruction and free muscle flap transfer in lower extremities that otherwise would have undergone major amputation.
Methods Patients Between January 1996 and December 2000, 25 patients (male 19, 76%; female 6, 24%) were selected for distal revascularization and free flap. Patient information was entered prospectively onto a database. Mean age was 64 years (33 –84 years). Seventeen patients (68%) had diabetes mellitus and of these, 11 were insulindependent. Other comorbidities were chronic renal insufficiency requiring dialysis (4), previous renal transplantation (3), osteomyelitis (3), primarily chronic polyarthritis (1), and thrombangitis obliterans (1). The
1078–5884/060635 + 05 $35.00/0 q 2004 Elsevier Ltd. All rights reserved.
M. Czerny et al.
636
Fig. 1. Tissue defect located at the heel with involvement of calcaneus.
majority of patients (80%) had already undergone previous vascular interventions as distal arterial reconstruction (10), percutaneous transluminal angioplasty (8) and thrombolysis (2). Soft tissue and bone defects were found on four major locations: crural (4), malleolar (4), heel (15), forefoot (4). All patients underwent diagnostic digital subtraction angiography prior to surgery.
Operative methods The surgical approach followed a set protocol. Initially, necrotic tissue was debrided in order to determine the extent of the defect and to eliminate florid infection
[Fig. 1]. One week later, the main procedure was performed by preparation of the anastomotic sites and the venous graft simultaneously to the flap harvest by two operative teams. The type of the flap being used was dependent upon the pedicle length and the size of the coverage required. The vein graft was prepared in order to provide a suitable side branch for anastomosis to the flap artery. If the gap between the side branch and the vascular pedicle was too large, a small venous bypass graft was inserted (Fig. 2). This approach avoided clamping of the bypass graft after establishment of graft flow. In some instances additional jump grafts to the posterior tibial artery were performed, in order to fixate the bypass behind the malleolus, where the anastomosis of bypass and flap was usually
Fig. 2. Intraoperative situs with the muscle vein anastomosed to the adjacent tibial artery as well as the muscle artery anastomosed to a venous jump graft. Eur J Vasc Endovasc Surg Vol 27, June 2004
Distal Bypass and Muscle Flap Transfer
637
Fig. 3. Intraoperative situs after reperfusion and fixation of the muscle flap in a patient with an ulcus located at the ankle.
situated. After reperfusion of the flap, tension was put on the muscle to reestablish the original fiber length and avoid bulkness. The muscle flap was trimmed to the desired size and was covered with split-thickness skin grafts (Fig. 3). In cases where the flap was positioned around the ankle, the ankle was stabilized either using Kirschner wires or an external fixator in order to improve flap incorporation. Follow-up Patients were reviewed daily for the first 10 days and thereafter as required until wound healing was completed. Graft patency was defined as a palpable pulse over the graft and the distal outflow artery or graft flow as detected by a colour-coded duplex scan. Flap viability was proven by oxygen uptake measurements during the first 10 days postoperatively and by inspection thereafter.
Results Intraoperative data
flaps used were rectus abdominis (6) and latissimus dorsi muscle (3). At 1-month, there were no deaths and 85% (23/27) of limbs had a patent graft and a viable flap. In three patients, early failure of the flap required lower leg amputation. In another patient, erosion of the bypass graft led to lower leg amputation. In two patients, partial loss of the free tissue flap made secondary wound closure necessary. Wound healing disturbancies at the flap harvesting site were observed in seven out of 27 procedures. Mean hospital stay was 34 days.
Functional status of the extremity Twenty patients regained full functional capacity of their lower extremities. Patients with defects in areas without weight bearing surfaces were able to walk after a mean duration of 22 days, whereas patients with defects in areas with weight bearing surfaces required a mean duration of 90 days to regain full functional capacity. The final result is shown in Fig. 4. Table 1. Vascular procedures performed
Mean operative time for this combined approach was 5.5 h (4 – 18 h). Twenty-three patients were reconstructed unilaterally, whereas two patients were reconstructed bilaterally. Bypass was performed using autologous vein (Table 1). Free flap transfer was mainly performed with gracilis muscle (18). Other
Vascular procedures performed
No. of procedures
Femoro-popliteal Femoro-crural Femoro-pedal Popliteo-pedal
3 3 4 17
Eur J Vasc Endovasc Surg Vol 27, June 2004
M. Czerny et al.
638
Fig. 4. Final result in a patient having regained full walking capacity.
Late results Twenty-one patients had a mean follow-up of 51 months (4 – 72 months). Twenty patients with 21 reconstructions had a patent graft and a viable flap at the time of follow-up. Therefore patency rate at this time was 77% (Fig. 5). Nineteen patients had full functional capacity of their lower extremities. In one patient, contralateral lower leg amputation was performed during follow-up.
Discussion Our results show that limb-salvage by distal arterial reconstruction and free muscle flap transfer in lower
Fig. 5. Freedom from major adverse events. Eur J Vasc Endovasc Surg Vol 27, June 2004
extremities otherwise destined for amputation, is feasible and provides excellent long-term outcomes. Due to microangiopathy and sensory neuropathy, patients with diabetes are at increased risk of developing tissue and bone necrosis in their lower extremities, than their non-diabetic atherosclerotic counterparts. The main sites at risk are the weightbearing areas. Due to impairment of the immune system, high rates of lower limb infections are also common in diabetics.7,8 As a consequence, a staged surgical approach was employed with initial debridement, followed by the main procedure one week later. Until recently, major amputation was the only option for patients with extensive tissue necrosis in combination with PAOD. Within the last decade, improved microsurgical techniques have enabled
Distal Bypass and Muscle Flap Transfer
effective free muscle transfer to cover soft tissue and bone defects. The concept of distal arterial revascularization and free muscle flap is supported by several case reports and limited series, reporting a primary patency rate between 57 and 100%.9 – 11 Our primary patency rate of 85% is well in line with other recently published series.3 – 6 However, the success of this combined approach seems to depend on careful selection of patients for this procedure. Illig found that the combination of diabetes and renal failure requiring hemodialysis was the strongest predictor of limb loss in patients after distal arterial reconstruction and free muscle flap transfer. We observed similar findings. All patients with early failure had diabetes and required hemodialysis. The size of the defect and consecutively the size of the free muscle flap also affects the success of the procedure. The gracilis muscle flap has the advantage of minimum donor morbidity, can be performed under loco-regional anesthesia and is tolerant of ischemia. Our second choice flap was the rectus abdominis muscle. If a more substantial defect was present a latissimus dorsi muscle flap was used. When using the latissimus dorsi muscle flap, we experienced problems with the blood supply of the mid and distal portions of the muscle, leading to partial flap loss in two and complete flap loss in one patient. Arterial inflow for the flap was obtained from the distal portion of the bypass conduit while venous outflow was by anastomosis to the tibial veins. In our opinion, avoiding calcified small tibial arteries as inflow vessels very much facilitates the whole procedure. To keep the whole procedure as minimally invasive as possible, the majority of operations were carried out under epidural anesthesia. Our mean duration of surgery was 5.5 h, which is well in line with others.3,4 The 4-year patient survival rate was 80% which compares favorably with results after conventional distal arterial revascularization.12 Long-term patency rate was 77%, which is excellent in patients who would otherwise have undergone major amputation. Other series report similar data with long-term patency rates of 57% after 5 years.4 – 6 Seventy percent of patients regained full functional capacity of their extremities. Time to full ambulation was greater in patients with defects in their weight-bearing areas. Previous studies of distal arterial reconstruction and free muscle flap
639
transfer report operative mortality rates between 0 and 10% and long-term ambulation rates of 60– 90%.1,3,13 In conclusion, soft tissue and bone defects in the lower limbs of patients especially with diabetes are a complex entity with a high risk of limb loss. In this situation, limb-salvage by distal arterial reconstruction and free muscle flap transfer is feasible and provides excellent long-term results.
References 1 Cronenwett JL, McDaniel MD, Zwolak RM, Walsh DB, Schneider JR, Reus FW et al. Limb salvage despite extensive tissue loss: free tissue transfer combined with distal revascularization. Arch Surg 1989; 124:609–615. 2 Serletti JM, Deuber MA, Guidera PM, Herres HR, Reading G, Hurrwitz SR et al. Atherosclerosis of the lower extremity and free-tissue reconstruction for limb-salvage. Plast Reconstr Surg 1995; 96:1136 –1144. 3 McCarthy III WJ, Matsumura JS, Fine NA, Dumanian GA, Pearce WH. Combined arterial reconstruction and free tissue transfer for limg-salvage. J Vasc Surg 1999; 29:814–820. 4 Illig K, Moran S, Serletti J, Ouriel K, Orlando G, Smith A et al. Combined free tissue transfer and infrainguinal bypass graft: an alternative to major amputation in selected patients. J Vasc Surg 2001; 33:17 –23. 5 Tukiainen E, Biancari F, Lepa¨ntalo M. Lower limb revascularization and free flap transfer for major ischemic tissue loss. World J Surg 2000; 24:1531–1536. 6 Vermassen FEG, van Landuyt K. Combined vascular reconstruction and free flap transfer in diabetic arterial disease. Diabetes Metab Res Rev 2000; 16(Suppl. 1):S33–S36. 7 Johnson JE. Infections and diabetes. In: Ellenberg M, ed. Diabetes mellitus: theory and practice. New York: McGraw-Hill, 1970: 734. 8 Casey JI. Host defense and infection in diabetes mellitus. In: Ellenberg M, ed. Diabetes mellitus: theory and practice, 3rd ed. New York: Medical Examiniation Publishing Co., 1983: 667. 9 Gooden MA, Gentile AT, Demas CP, Berman SS. Salvage of femoropedal bypass graft complicated by interval gangrene and vein graft blowout using a flow-through radial forearm fasciocutaneous free flap. J Vasc Surg 1997; 26:711–714. 10 May JW, Halls MH, Simon SR. Free microvascular muscle flaps with skin graft reconstruction of extensive defects of the foot: a clinical and gait analysis study. Plast Reconstr Surg 1985; 75: 627–641. 11 Briggs SE, Banis JC, Kaebnick H, Silverberg B, Acland RD. Distal revascularization and microvascular free tissue transfer: an alternative to amputation in ischemic lesions of the lower extremity. J Vasc Surg 1985; 2:806–811. 12 Gupta AK, Girishkumar H. Lower extremity revascularization. J Cardiovasc Surg 1993; 34:229–236. 13 Ciresi KF, Anthony JP, Hoffman WY, Bowersox JC, Reilly LM, Rapp JH. Limb salvage and wound coverage in patients with large ischemic ulcers: a multidisciplinary approach with revascularization and free tissue transfer. J Vasc Surg 1993; 18:648– 655. Accepted 26 February 2004
Eur J Vasc Endovasc Surg Vol 27, June 2004