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Combined arterial reconstruction and free tissue transfer for limb salvage
Combined arterial reconstruction and free tissue transfer for limb salvage Walter J. McCarthy III, MD, Jon S. Matsumura, MD, Neil A. Fine, MD, Gregory A. Dumanian, MD, and William H. Pearce, MD, Chicago, Ill Purpose: Lower-extremity arterial anatomy that is insufficient for successful vein bypass grafting and major proximal foot wounds often lead to leg amputation in patients with severe ischemia. Free tissue transfer, which can provide limb salvage in these patients after arterial reconstruction, was studied. Methods: During a 45-month period, 21 patients who otherwise would have undergone leg amputation were treated with arterial bypass by means of vein grafting and free tissue transfer. Ages of the patients ranged from 40 to 73 years (average, 59 years); 18 of the 21 patients had diabetes mellitus; and all patients except one were men. Arterial reconstruction was performed from the femoral (nine of 21 patients) or popliteal artery (12 of 21 patients) to the posterior tibial (eight patients), dorsalis pedis (five patients), peroneal (three patients), popliteal (one patient), or anterior tibial artery (one patient), or directly to the free flap (three patients). The tissue transferred included latissimus dorsi (five patients), rectus abdominus (five patients), omentum (five patients), gracilis (two patients), radial forearm flaps (three patients), and a scapular flap (one patient). Foot defects were debrided, including the appropriate toe or transmetatarsal amputation, covered with the transferred flap, and then split-thickness skin grafted. Arterial flow for all flaps was through the vein grafts, with direct arterial anastomosis and with venous outflow through adjacent tibial veins. Results: All 21 procedures were successful initially, without operative mortality, but three failed within 4 weeks because of uncontrolled infection (two) or embolization from a remote site (one) and required below-knee amputation. Grafts remained patent in 18 procedures, and follow-up of this cohort ranged from 1 to 45 months (mean, 13.3 months). Two patients died, one after 4 months and one after 6 months, of unrelated illness; at the time of death, they had functioning grafts. The remaining 19 patients are alive. Of these, 15 have patent arterial grafts, all viable free flaps. Thus, limb salvage was accomplished in 18 of 21 (86%) patients who otherwise would have required below-knee amputation. Conclusion: Patients destined for leg amputation despite aggressive traditional arterial bypass grafting methods can achieve limb salvage with the additional technique of free tissue transfer. (J Vasc Surg 1999;29:814-20.)
Despite remarkable advances in surgical methods to revascularize the lower extremity in the last 20 years, some patients still are left with leg amputation as their only recourse. These patients typically are From the Division of Vascular Surgery (Drs Matsumura and Pearce) and the Division of Plastic Surgery (Drs Fine and Dumanian), Department of Surgery, Northwestern University Medical School, and the Section of Vascular Surgery (Dr McCarthy), Department of Cardiovascular-Thoracic Surgery, Rush-Presbyterian-St. Luke’s Medical Center. Presented at the Twenty-second Annual Meeting of the Midwestern Vascular Surgical Society, Dearborn, Mich, Sep 25–26, 1998. Reprint requests: Walter J. McCarthy III, MD, Rush-PresbyterianSt. Luke’s Medical Center, 1653 West Congress Parkway, Chicago, IL 60612-3833. Copyright © 1999 by The Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter. 0741-5214/99/$8.00 + 0 24/6/96981
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evaluated for elective treatment of ischemic foot and leg tissue loss by means of angiography and are found to not have a tibial or pedal artery sufficient to accept a distal bypass graft anastomosis. Occasionally, a recipient artery exists, but is beneath an area of soft tissue loss, excluding its use for bypass grafting. Other patients are seen in consultation and not recommended for angiographic evaluation because they have such extensive tissue destruction. These patients have large areas of dorsal or plantar foot skin loss, proximal foot osteomyelitis or joint involvement, or combinations of these problems. These wounds would not heal, even with normalized arterial circulation and partial foot amputation. Therefore, these patients generally undergo leg amputation to achieve infection control and wound closure. To modify the dismal prognosis that these patients face, the technique of free tissue transfer can
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be applied after a conventional arterial bypass grafting procedure is completed.1 The transferred tissue flap not only provides wound coverage that can be immediately covered with split-thickness skin grafts, but also increases the flow through the newly constructed bypass graft.2 This preliminary report, spanning nearly 4 years, outlines the efforts by vascular and plastic surgeons working as a team to achieve limb salvage for the group of patients previously described. In every case, leg amputation would have been recommended had the free tissue transfer technique not been available. These are patients who would never be included in a conventional series of, for example, in situ bypass grafting operations. They thus represent an extension of our ability to achieve reliable limb salvage in patients with severe leg ischemia. PATIENTS AND METHODS A cohort of 21 patients was selected during a 45month period from patients seen in consultation by the Vascular Surgery Service at Northwestern Memorial Hospital (19 patients) or the Lakeside Veterans Administration Hospital (2 patients) in Chicago, Ill. The patients were also examined in detail preoperatively by the Plastic Surgery Microsurgery Service. In every patient, it was evident that free tissue transfer would be necessary to avert a leg amputation. The reasons that patients would have otherwise required leg amputation can be broadly grouped into four categories. Many patients are in more than one group. Extensive heel or plantar foot destruction was seen in 11 patients; extensive exposed bone or tendon was seen in 19 patients. The site of the potential distal anastomosis was beneath necrotic skin in two patients. The fourth group comprised three patients who had no distal vessel to which the vein grafts could be anastomosed. The vein grafts were anastomosed directly to the free-flaps in these three patients. Patient ages ranged from 40 to 73 years, with an average age of 59 years. All patients except one were men, and 18 of the 21 patients had diabetes mellitus. Ten patients admitted to being current smokers, 19 had hypertension, and 14 had coronary disease. Sixteen of the patients were white, two were black, two were Hispanic, and one was Asian. The arterial reconstructions and free tissue transferal are outlined in Table I. Briefly, arterial reconstruction was performed with vein grafting in every case. Arm veins were used in two patients, half of the saphenous grafts were reversed, and half were without valves, either in situ or with lysed valves in a portion of mobilized vein. The lesser saphenous vein was used once, and a com-
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posite-sequential graft was used once. These bypass grafts were placed from the femoral artery in nine of the 21 patients and from the popliteal artery in 12 of the 21 patients, with distal anastomosis to the posterior-tibial artery (eight patients), dorsalis pedis artery (five patients), peroneal artery (three patients), popliteal artery (one patient), anterior-tibial artery (one patient), or directly to an omental free flap (three patients). The tissue transferred included the latissimus dorsi muscle (five patients), rectus abdominus muscle (five patients), omentum (five patients), gracilis muscle (two patients), radical forearm flap (three patients), and scapular flap (one patient). The omentum and muscle flaps were covered with split-thickness skin grafts at the time of the operation. As a general principle, the tissue transfer was completed during the same operation as the arterial reconstruction. However, in four patients free flaps were added later, as a staged procedure. All the free tissue arterial anastomoses were performed end-to-side to the distal vein graft, except in the three patients with end-to-end anastomosis directly to the omental flaps. The free flap venous outflow was conducted through adjacent tibial veins. Free flap arterial and venous anastomoses were placed by means of an operating microscope. Very aggressive debridement, including toe or transmetatarsal amputation, was usually performed at the time of the definitive operation. It was occasionally necessary to perform an initial debridement to determine if there was enough viable tissue to justify entering the combined arterial bypass grafting, free-tissue operation. Heparin was used intraoperatively, but patients were not routinely anticoagulated postoperatively. During the free-flap portion of the operation, 5000 units of unfractionated Heparin was given subcutaneously with 60 mg intravenous ketorolac tromethamine (Toradol). Aspirin was given for chronic platelet inhibition. The patient with the compositesequential bypass graft was given Coumadin postoperatively. Outpatient follow-up was conducted, usually weekly, until all wounds were closed. Graft patency was determined by means of ankle-brachial index and by observing the skin grafted area. Follow-up patency was monitored by means of duplex scanning at 3, 6, and 12 months. TECHNIQUE The common characteristics, advantages, and disadvantages of the six tissue flaps used in this series follow. These parameters were used to guide selection of the best flaps for given cases. Omentum. The omentum is usually available
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Table I. Arterial reconstructions and free-tissue transferal Inflow artery 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Popliteal Popliteal Popliteal Femoral Popliteal Femoral Femoral Popliteal Popliteal Popliteal Popliteal Femoral (SFA) Popliteal Femoral Popliteal Femoral Femoral Femoral Femoral Popliteal Popliteal
Distal anastomosis
Tissue flap
Omentum Posterior-tibial Dorsalis pedis Posterior-tibial Omentum Peroneal Peroneal Dorsalis pedis Anterior-tibial & posterior-tibial Dorsalis pedis Dorsalis pedis Omentum Posterior-tibial Popliteal Posterior-tibial Posterior-tibial Posterior-tibial Peroneal Dorsalis pedis Posterior-tibial Posterior-tibial
Omentum Rectus abdominus Gracilis Rectus abdominus Omentum Latissimus dorsi Latissimus dorsi Gracilis Rectus abdominus Rectus abdominus Radical forearm Omentum Radical forearm Omentum Latissimus dorsi Scapular Latissimus dorsi Radical forearm Omentum Rectus abdominus Latissimus dorsi
SFA, superficial femoral artery.
and can cover very large areas or be extended over a remarkable length.3-6 It provides outstanding tissue ingrowth and is an excellent bed for skin grafting. It is extremely malleable, which allows contouring to almost any shape, and the omentum rarely is involved with atherosclerosis. A laparotomy is required for harvest, which is a disadvantage, but this can be done by a second team while the leg bypass graft is being constructed. Rectus abdominis. The rectus abdominis is a thick muscle with a long pedicle that can be harvested by a second team during the arterial bypass grafting procedure. The inferior epigastric artery is often involved with atherosclerosis, but we have found that even with some atherosclerosis the flap is usable. The thickness is useful for weight-bearing surfaces. Latissimus dorsi. The latissimus dorsi is a broad flap with a long pedicle length. It is usually not involved with atherosclerosis. Its use requires special attention when positioning the patient. Radial forearm. This is a small, thin flap that is used with its skin. It can be taken with an extremely long pedicle from the elbow level. The radial artery can be used as a “flow-through graft” with distal anastomosis, for example, to the dorsalis pedis artery.7 It is useful for providing coverage of exposed ankle tendons and bone. Scapular-parascapular. The scapular-parascapular muscle flap is covered with thick durable skin and is rarely involved with atherosclerosis.
Gracilis. The gracilis is a small flap that can be taken through the same incisions as the arterial bypass graft, with little additional morbidity. It is commonly involved with atherosclerosis. As a general principle, muscle flaps covered with split-thickness skin grafts provide adequate weightbearing surfaces. RESULTS All 21 operations were initially successful, with vein graft patency and transferred tissue viability. One patient had to return to the operating room the evening of the operation for successful modification of the vein graft-muscle flap arterial anastomosis. There was no operative mortality. Two early failures resulted from overwhelming sepsis involving the free flap, and both of the patients in these cases required below-knee amputations. A third patient had angiography performed on his other leg and sustained substantial embolization to his omental graft, portions of which necrosed, making limb salvage impossible. He also required a below-knee amputation. These failures all occurred within the first 4 weeks postoperative. Re-skin grafting of portions of the free flap was required in three patients, and in one patient, the flap itself had to be debrided and was successfully reapplied. Subflap hematoma evacuation was necessary in one patient. Partial venous thrombosis of the free flap complicated one case, with loss of some of the muscle tissue.
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The other follow-up periods ranged from 1 to 45 months (average, 13.3 months). Two patients died, one 4 months postoperative and one 6 months postoperative, of illness unrelated to their legs or operations. All the bypass grafts except one remained patent, and the transferred tissue was viable in all of the 16 surviving patients with viable flaps after 4 weeks. One patient had a viable free flap, but occlusion of the vein graft was shown by means of duplex examination. All the patients have achieved complete wound healing and effective weight bearing on their affected limb, with the exception of one patient who is wheelchair-bound. Thus, 18 of 21 (86%) patients attained limb salvage. The total operating time was prolonged. The operation time in the four patients with staged operations was 6 to 13 hours (mean, 8 hours) when the times for the two operations were combined. When the bypass grafting procedure and free flap procedure were conducted together, the operating time was 4 to 8 hours (mean, 5 hours). The time to complete healing was also prolonged for some patients, ranging from 1 month to 8 months (mean, 3.8 months). DISCUSSION The use of free tissue transfer as an adjunct to conventional arterial bypass grafting surgery is intriguing. In the present study, 21 patients destined for leg amputation achieved an 86% limb salvage using this method. Despite the extended operating time requirements, there was no related mortality. The concept involved is simple and is supported by a number of small reports that have appeared since 1982, with at least 135 patients treated in a similar way.1,2,8-18 Patency rates from these collected papers range between 57% and 100%, with average follow-up times of 6 to 24 months. In the current study, all the grafts functioning after 1 month have remained patent except one. Why, then, is there not more widespread application of such a powerful limb-salvage method? The skills of a vascular surgeon experienced in tibial bypass grafting surgery are sufficient to accomplish the inflow portion of this operation. The vascular surgeon must then recruit the skills of a microvascular surgeon comfortable with free tissue transfer to complete an effective team. An enthusiastic and supportive team is critical for these demanding operations. Arterial inflow source for the free muscle flaps or omentum in the current study was uniformly obtained from the distal portion of a vein bypass graft, and suturing to this soft, disease-free tissue is less technically demanding than using a small, sometimes calci-
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fied, tibial artery. Serletti et al2 also used vein grafts for inflow, but used the reperfused anterior or posterior tibial arteries for free-flap perfusion after femoralpopliteal bypass grafting if they were in continuity. In the present study, the distal vein graft anastomosis was sometimes moved closer to the ankle to avoid dependence on any native tibial artery for inflow, and this may help to explain the reliable patency observed. Perhaps the most interesting subset of patients in this report are the three who had reconstructions with end-to-end anastomoses to omental free flaps. These three patients all had soft tissue loss and were without a tibial artery sufficient to support a distal bypass grafting anastomosis. Thus, there was no new anastomosis directly to the native arterial system. Although one of these limbs was lost because of embolization into the omental flap after angiography in the postoperative period, the other two patients did well. Their split-thickness skin grafts healed, and, remarkably, the entire involved foot began to show signs of increased perfusion. This “neovascularization”19 was commented on by Cutler in a discussion of the work by Cronenwett et al.1 In that case, the neovascularization was seen after an end-to-end anastomosis with a serratus muscle flap. Neovascularization has been quantitated with both cutaneous fluorescein methods and conventional angiography, but the patients in our study were not examined with angiography because of the risks involved. Omentum has been used to relieve limb ischemia, both as a pedicle reconstruction20 and as a free flap anastomosed to patent native arteries. In fact, pedicle techniques have been developed that allow omentum still deriving its blood supply from the right gastroepiploic artery to reach across the inguinal ligament to the ankle in some patients.3 In the present study, arterial flow for the omental flap came directly from the vein bypass graft. Omentum has even been used to relieve rest pain with some success by creating a pocket for the omentum along the medial aspect of the thigh and calf. These reports also mention an increased limb perfusion remote from the omental graft.21 In the present study, all the free flaps received arterial inflow from direct anastomosis to the previously constructed venous conduit bypass grafts. One patient had a composite-sequential graft with a proximal femoropopliteal polytetrafluoroethylene (PTFE) section and a distal reversed saphenous vein to the posterior tibial artery. The free tissue flap was anastomosed distally to the venous portion. In this series, patients without venous conduit were felt not to be candidates for such an extensive operation. However, Kasablain et al have reported such a procedure, using
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PTFE for inflow with good results for as long as 3 years.22 In their case report, the tissue flap was anastomosed directly to the PTFE. Although the practice of using PTFE for inflow could be debated, it is possible that the restrictions imposed in the current study were too strict. SUMMARY Combining the two well-established surgical methods of venous conduit arterial bypass grafting and free tissue transfer creates a powerful technique for limb salvage. It enlarges the pool of patients with severe leg ischemia who have an alternative to certain leg amputation. Patients with extensive tissue loss, tibial arteries beneath infected wounds, and those without adequate tibial arterial anatomy for distal anastomosis can now be helped. In many medical centers, the organization of an enthusiastic team to perform these operations may be the main obstacle that needs to be overcome. REFERENCES 1. Cronenwett JL, McDaniel MD, Zwolak RM, Walsh DB, Schneider JR, Reus WF, et al. Limb salvage despite extensive tissue loss: Free tissue transfer combined with distal revascularization. Arch Surg 1989;124:609-15. 2. Serletti JM, Deuber MA, Guidera PM, Herrers HR, Reading G, Hurrwitz SR, et al. Atherosclerosis of the lower extremity and free-tissue reconstruction for limb salvage. Plast Reconstr Surg 1995;96:1136-44. 3. Nishimura A, Sano F, Nakanishi Y, Koshino I, Kasai Y. Omental transplantation for relief of limb ischemia. Surg Forum 1977;28:213-5. 4. Casten DF, Alday ES. Omental transfer for revascularization of the extremities. Surg Gynecol Obstet 1971;301-4. 5. Goldsmith HA. Salvage of end stage ischemic extremities by intact omentum. Surgery 1980;88,5:732-6. 6. Hoshino H, Nakayama K, Igari S, Honda K. Long-term results of omental transplantation for chronic occlusive arterial diseases. Int Surg 1983;68:47-50. 7. Gooden MA, Gentile AT, Demas CP, Berman SS, Mills JL. 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;26,4: 711-4. 8. May JW, Halls MJ, 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;75:627-41.
DISCUSSION Dr James Schuler (Chicago, Ill). This represents some truly superb results in what I think most of us would agree is a group of patients that almost certainly would have ended up with below-the-knee amputations, so I would like to say “well done.”
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9. 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;2:806-11. 10. Mimoun M, Hilligot P, Baux S. The nutrient flap: A new concept of the role of the flap and application to the salvage of arteriosclerotic lower limbs. Plast Reconstr Surg 1989;84:458-67. 11. Shenaq Sm, Dinh TA. Foot salvage in arteriosclerotic and diabetic patients by free flaps after vascular bypass: Report of two cases. Microsurgery 1989;10:310-4. 12. Shestak KC, Fitz DG, Newton ED, Swartz WM. Expanding the horizons in treatment of severe peripheral vascular disease using microsurgical techniques. Plast Reconstr Surg 1990;85:406-11. 13. Greenwald LL, Comerota AJ, Mitra A, Grosh JD, White JV. Free vascularized tissue transfer for limb salvage in peripheral vascular disease. Ann Vasc Surg 1990;4:244-54. 14. Chowdary RP, Celani VJ, Goodreau JJ, McCullough JL, McDonald KM, Nicholas GG. Free-tissue transfers for limb salvage utilizing in situ saphenous vein bypass conduit as the inflow. Plast Reconstr Surg 1991;87:529-35. 15. Sonntag BV, Murphy RX, Chernofsky MA, Chowdary RP. Microvascular steal phenomenon in lower extremity reconstruction. Ann Plast Surg 1995;34:336-40. 16. 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; 18:648-55. 17. Serletti JM, Hurwitz SR, Jones JA, Herrera HR, Reading GP, Ouriel K, et al. Extension of limb salvage by combines vascular reconstruction and adjunctive free-tissue transfer [discussion by Cronenwett JR]. J Vasc Surg 1993;18:972-80. 18. Lepantalo M, Tukiainen E. Combined vascular reconstruction and microvascular muscle flap transfer for salvage of ischemic legs with major tissue loss and wound complications. Eur J Vasc Endovasc Surg 1996;12;65-9. 19. VanLanduyt K, Monstrey S, Blondeel P, Tonnard P, Vermassen F. Revascularization by ingrowth of a free flap: Fact or fiction? Microsurgery 1996;17:417-22. 20. Hoshino S, Hamada O, Iwaya F, Takahira H, Honda K. Omental transplantation for chronic occlusive arterial diseases. Int Surg 1979;64,5:21-9. 21. Kasabian AK, Glat PM, Eidelman Y, Karp N, Giangola G. Limb salvage with microvascular free flap reconstruction using simultaneous polytetrafluoroethylene graft for inflow. Ann Plast Surg 1995;35,3:310-5. 22. Maurya D, Singhal S, Gupta HC, Hence IP, Sharma BR. Pedicled omental grafts in the revascularization of ischemic lower limbs in Buerger’s Disease. Int Surg 1985;70:253-5.
Submitted Sep 24, 1998; accepted Jan 4, 1999.
At the University of Illinois in Chicago in mid-1989, we formed a multidisciplinary team with plastic surgery. We had access at that time to two young, well-trained plastic surgeons who were experienced in microvascular technique, and we’ve been using free tissue transfer for about 10 years.
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We’ve used it in cases similar to those you’ve presented, but we’ve also used it in some other complex lower-extremity wound healing problems. Primarily, free tissue transfer has been used to achieve healing in recalcitrin or multiply recurrent venous stases ulcers. We’ve also used it in patients with combined arterial and venous ulcers. It has also been used to cover up exposed orthopedic hardware after compound fractures or with osteomyelitis. One of the ways in which we found it to be most useful is in the patient with diabetes mellitus who has extensive digital occlusive disease and plantar arch vessel occlusive disease, but who has axial patency and hemodynamically normal inflow to the ankle. In those patients, either omentum or rectus abdominous flaps can salvage feet and limbs that would otherwise be amputated. I would like to reenforce one of the things you said: forming a good working alliance with microvascular plastic surgeons is really essential. I’m convinced that we have received a lot of referrals and salvaged a lot of limbs that we would never have if not for the relationship that developed with our plastic surgeons. I have three questions. The first is, have you had any experience with performing extensive partial calcaniectomy in your patients with diabetes mellitus and then covering the defect with a flap? We’ve encountered one failure in a patient who had extensive calcaneal osteomyelitis. We applied a rectus abdominous flap, which took and stayed healed, but the patient ended up walking on a dysfunctional foot. He will probably eventually have a below-knee amputation. My second question is, have you encountered any patients in whom the femoral-to-tibial bypass grafting procedure failed and yet the flap remained viable? We encountered one patient who had a femoroperineal bypass graft. Two years after that the bypass graft occluded but the rectus abdominous free flap did not die, the wound did not recur, and, in fact, the patient has gone an additional 2 years with the femoroperineal bypass graft occluded and the wound healed. The only way we could explain this was on the basis of neovascularity, which is poorly understood. My last question is, do you have any intermediate or long-term cost-benefit analysis comparing this procedure with primary below-knee amputation? We have a number of managed care referrals, and when the medical directors or the gatekeepers find out the up-front costs of these combined procedures, they go into a state of shock. So far, they haven’t failed to continue referring patients, but each time it gets harder and harder to justify to them saving these limbs with some very large up-front costs. I would like to know if you have any data that would keep them at bay. Once again, I think this was a great paper, and I commend you. Dr Walter J. McCarthy III. Thank you. We have not done a major resection of the calcaneus, although we have had several cases in which we had to shave the calcaneus superficially. I appreciate the problems that would occur with a major deformity of that bone. About graft occlusion and flap viability, we actually have one case where we’re not sure, but, just in the last week as
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we were preparing the manuscript, it appeared that the bypass graft may have occluded yet the flap is completely viable. We’re submitting that patient to a duplex scan to see what’s going on with the graft. There are reports in the plastic surgery literature of flaps that survive after their inflow arteries occlude because of their neovascularization. In preparing the slides, I said that all the free flaps were viable, and all the grafts except one are patent. The cost-benefit analysis may be a bit shocking. The postoperative care for these patients is very extensive; they often end up coming back for additional minor operations and office visits. We share the office visits with the plastic surgeons, and patients often come back to see one of us about once a week for a period of months, until everything is healed. The benefit of keeping people out of a nursing home is extensive. These patients are able to live independently, whereas many of them would have otherwise ended up in a nursing home. We have one patient who cares for his wife, so actually we’re keeping two patients out of nursing homes by preventing his amputation. Dr Alexander D. Shepard (Detroit, Mich). I, too, congratulate you on really spectacular results, but I have to ask a question based on our results at Ford Hospital in Detroit. We, too, have had fairly extensive experience using the efforts of our plastic surgery team. Our results have not been as good long-term as your results. Now your “long term” is only slightly longer than a year. We’ve used the free flap technique in some patients with significant neuropathy and had a spectacular result, saw them back in the office with everything healed, and then, a few months later, had them come back with a recurred ulcer. Our problem basically is one, I think, of patient selection. I was wondering if you could give us some hints or guidelines as to who is really a candidate for this procedure. Which patients do you see for a first office visit and say to yourself, “there’s no way we’re going to put them through all this, through the expense of these two procedures,” and decide that a primary amputation would, in fact, be in their best interest at the outset? Dr McCarthy. I think that patients need to be potentially ambulatory. If they are not going to be able to get out of their wheelchairs, and you can anticipate that beforehand, then it’s probably better just to go ahead with a leg amputation. Second, if all the weight-bearing surface of the foot is involved, I think it might be excessive to go ahead with this sort of reconstruction. Those probably are two good guiding parameters, besides just being able to physically achieve wound healing. There are some patients who have so much infection in their ankle joint, for example, that you can anticipate not being able to get them to heal, even with good vascularized pedicle over the area. There are also patients who are seen with foot sepsis severe enough that, as in the two cases that failed primarily because of sepsis, one could anticipate that, even with a flap in place, the flap and antibiotics would not control the sepsis. Dr Joseph J. Hurley (St Louis, Mo). How high up were you able to make the omental anastomosis to your
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blood supply? Were you able to take the omental vessel anastomosis and plug it in by the popliteal and run that graft all the way down the leg? Dr McCarthy. The omentum can be pedicled and extended over a very long length. In fact, there are techniques that we didn’t use, but one can actually use to
make the anastomosis based on a patch of the gastroduodenal artery to the common femoral artery and then pedicle the omentum all the way down to the midcalf, or even to the ankle. We pedicled it to some extent, but generally began the omentum in the midcalf and then brought it down over the entire foot.
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Despite remarkable advances in surgical methods to revascularize the lower extremity in the last 20 years, some patients still are left with leg amputation as their only recourse. These patients typically are From the Division of Vascular Surgery (Drs Matsumura and Pearce) and the Division of Plastic Surgery (Drs Fine and Dumanian), Department of Surgery, Northwestern University Medical School, and the Section of Vascular Surgery (Dr McCarthy), Department of Cardiovascular-Thoracic Surgery, Rush-Presbyterian-St. Luke’s Medical Center. Presented at the Twenty-second Annual Meeting of the Midwestern Vascular Surgical Society, Dearborn, Mich, Sep 25–26, 1998. Reprint requests: Walter J. McCarthy III, MD, Rush-PresbyterianSt. Luke’s Medical Center, 1653 West Congress Parkway, Chicago, IL 60612-3833. Copyright © 1999 by The Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter. 0741-5214/99/$8.00 + 0 24/6/96981
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evaluated for elective treatment of ischemic foot and leg tissue loss by means of angiography and are found to not have a tibial or pedal artery sufficient to accept a distal bypass graft anastomosis. Occasionally, a recipient artery exists, but is beneath an area of soft tissue loss, excluding its use for bypass grafting. Other patients are seen in consultation and not recommended for angiographic evaluation because they have such extensive tissue destruction. These patients have large areas of dorsal or plantar foot skin loss, proximal foot osteomyelitis or joint involvement, or combinations of these problems. These wounds would not heal, even with normalized arterial circulation and partial foot amputation. Therefore, these patients generally undergo leg amputation to achieve infection control and wound closure. To modify the dismal prognosis that these patients face, the technique of free tissue transfer can
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be applied after a conventional arterial bypass grafting procedure is completed.1 The transferred tissue flap not only provides wound coverage that can be immediately covered with split-thickness skin grafts, but also increases the flow through the newly constructed bypass graft.2 This preliminary report, spanning nearly 4 years, outlines the efforts by vascular and plastic surgeons working as a team to achieve limb salvage for the group of patients previously described. In every case, leg amputation would have been recommended had the free tissue transfer technique not been available. These are patients who would never be included in a conventional series of, for example, in situ bypass grafting operations. They thus represent an extension of our ability to achieve reliable limb salvage in patients with severe leg ischemia. PATIENTS AND METHODS A cohort of 21 patients was selected during a 45month period from patients seen in consultation by the Vascular Surgery Service at Northwestern Memorial Hospital (19 patients) or the Lakeside Veterans Administration Hospital (2 patients) in Chicago, Ill. The patients were also examined in detail preoperatively by the Plastic Surgery Microsurgery Service. In every patient, it was evident that free tissue transfer would be necessary to avert a leg amputation. The reasons that patients would have otherwise required leg amputation can be broadly grouped into four categories. Many patients are in more than one group. Extensive heel or plantar foot destruction was seen in 11 patients; extensive exposed bone or tendon was seen in 19 patients. The site of the potential distal anastomosis was beneath necrotic skin in two patients. The fourth group comprised three patients who had no distal vessel to which the vein grafts could be anastomosed. The vein grafts were anastomosed directly to the free-flaps in these three patients. Patient ages ranged from 40 to 73 years, with an average age of 59 years. All patients except one were men, and 18 of the 21 patients had diabetes mellitus. Ten patients admitted to being current smokers, 19 had hypertension, and 14 had coronary disease. Sixteen of the patients were white, two were black, two were Hispanic, and one was Asian. The arterial reconstructions and free tissue transferal are outlined in Table I. Briefly, arterial reconstruction was performed with vein grafting in every case. Arm veins were used in two patients, half of the saphenous grafts were reversed, and half were without valves, either in situ or with lysed valves in a portion of mobilized vein. The lesser saphenous vein was used once, and a com-
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posite-sequential graft was used once. These bypass grafts were placed from the femoral artery in nine of the 21 patients and from the popliteal artery in 12 of the 21 patients, with distal anastomosis to the posterior-tibial artery (eight patients), dorsalis pedis artery (five patients), peroneal artery (three patients), popliteal artery (one patient), anterior-tibial artery (one patient), or directly to an omental free flap (three patients). The tissue transferred included the latissimus dorsi muscle (five patients), rectus abdominus muscle (five patients), omentum (five patients), gracilis muscle (two patients), radical forearm flap (three patients), and scapular flap (one patient). The omentum and muscle flaps were covered with split-thickness skin grafts at the time of the operation. As a general principle, the tissue transfer was completed during the same operation as the arterial reconstruction. However, in four patients free flaps were added later, as a staged procedure. All the free tissue arterial anastomoses were performed end-to-side to the distal vein graft, except in the three patients with end-to-end anastomosis directly to the omental flaps. The free flap venous outflow was conducted through adjacent tibial veins. Free flap arterial and venous anastomoses were placed by means of an operating microscope. Very aggressive debridement, including toe or transmetatarsal amputation, was usually performed at the time of the definitive operation. It was occasionally necessary to perform an initial debridement to determine if there was enough viable tissue to justify entering the combined arterial bypass grafting, free-tissue operation. Heparin was used intraoperatively, but patients were not routinely anticoagulated postoperatively. During the free-flap portion of the operation, 5000 units of unfractionated Heparin was given subcutaneously with 60 mg intravenous ketorolac tromethamine (Toradol). Aspirin was given for chronic platelet inhibition. The patient with the compositesequential bypass graft was given Coumadin postoperatively. Outpatient follow-up was conducted, usually weekly, until all wounds were closed. Graft patency was determined by means of ankle-brachial index and by observing the skin grafted area. Follow-up patency was monitored by means of duplex scanning at 3, 6, and 12 months. TECHNIQUE The common characteristics, advantages, and disadvantages of the six tissue flaps used in this series follow. These parameters were used to guide selection of the best flaps for given cases. Omentum. The omentum is usually available
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Table I. Arterial reconstructions and free-tissue transferal Inflow artery 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Popliteal Popliteal Popliteal Femoral Popliteal Femoral Femoral Popliteal Popliteal Popliteal Popliteal Femoral (SFA) Popliteal Femoral Popliteal Femoral Femoral Femoral Femoral Popliteal Popliteal
Distal anastomosis
Tissue flap
Omentum Posterior-tibial Dorsalis pedis Posterior-tibial Omentum Peroneal Peroneal Dorsalis pedis Anterior-tibial & posterior-tibial Dorsalis pedis Dorsalis pedis Omentum Posterior-tibial Popliteal Posterior-tibial Posterior-tibial Posterior-tibial Peroneal Dorsalis pedis Posterior-tibial Posterior-tibial
Omentum Rectus abdominus Gracilis Rectus abdominus Omentum Latissimus dorsi Latissimus dorsi Gracilis Rectus abdominus Rectus abdominus Radical forearm Omentum Radical forearm Omentum Latissimus dorsi Scapular Latissimus dorsi Radical forearm Omentum Rectus abdominus Latissimus dorsi
SFA, superficial femoral artery.
and can cover very large areas or be extended over a remarkable length.3-6 It provides outstanding tissue ingrowth and is an excellent bed for skin grafting. It is extremely malleable, which allows contouring to almost any shape, and the omentum rarely is involved with atherosclerosis. A laparotomy is required for harvest, which is a disadvantage, but this can be done by a second team while the leg bypass graft is being constructed. Rectus abdominis. The rectus abdominis is a thick muscle with a long pedicle that can be harvested by a second team during the arterial bypass grafting procedure. The inferior epigastric artery is often involved with atherosclerosis, but we have found that even with some atherosclerosis the flap is usable. The thickness is useful for weight-bearing surfaces. Latissimus dorsi. The latissimus dorsi is a broad flap with a long pedicle length. It is usually not involved with atherosclerosis. Its use requires special attention when positioning the patient. Radial forearm. This is a small, thin flap that is used with its skin. It can be taken with an extremely long pedicle from the elbow level. The radial artery can be used as a “flow-through graft” with distal anastomosis, for example, to the dorsalis pedis artery.7 It is useful for providing coverage of exposed ankle tendons and bone. Scapular-parascapular. The scapular-parascapular muscle flap is covered with thick durable skin and is rarely involved with atherosclerosis.
Gracilis. The gracilis is a small flap that can be taken through the same incisions as the arterial bypass graft, with little additional morbidity. It is commonly involved with atherosclerosis. As a general principle, muscle flaps covered with split-thickness skin grafts provide adequate weightbearing surfaces. RESULTS All 21 operations were initially successful, with vein graft patency and transferred tissue viability. One patient had to return to the operating room the evening of the operation for successful modification of the vein graft-muscle flap arterial anastomosis. There was no operative mortality. Two early failures resulted from overwhelming sepsis involving the free flap, and both of the patients in these cases required below-knee amputations. A third patient had angiography performed on his other leg and sustained substantial embolization to his omental graft, portions of which necrosed, making limb salvage impossible. He also required a below-knee amputation. These failures all occurred within the first 4 weeks postoperative. Re-skin grafting of portions of the free flap was required in three patients, and in one patient, the flap itself had to be debrided and was successfully reapplied. Subflap hematoma evacuation was necessary in one patient. Partial venous thrombosis of the free flap complicated one case, with loss of some of the muscle tissue.
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The other follow-up periods ranged from 1 to 45 months (average, 13.3 months). Two patients died, one 4 months postoperative and one 6 months postoperative, of illness unrelated to their legs or operations. All the bypass grafts except one remained patent, and the transferred tissue was viable in all of the 16 surviving patients with viable flaps after 4 weeks. One patient had a viable free flap, but occlusion of the vein graft was shown by means of duplex examination. All the patients have achieved complete wound healing and effective weight bearing on their affected limb, with the exception of one patient who is wheelchair-bound. Thus, 18 of 21 (86%) patients attained limb salvage. The total operating time was prolonged. The operation time in the four patients with staged operations was 6 to 13 hours (mean, 8 hours) when the times for the two operations were combined. When the bypass grafting procedure and free flap procedure were conducted together, the operating time was 4 to 8 hours (mean, 5 hours). The time to complete healing was also prolonged for some patients, ranging from 1 month to 8 months (mean, 3.8 months). DISCUSSION The use of free tissue transfer as an adjunct to conventional arterial bypass grafting surgery is intriguing. In the present study, 21 patients destined for leg amputation achieved an 86% limb salvage using this method. Despite the extended operating time requirements, there was no related mortality. The concept involved is simple and is supported by a number of small reports that have appeared since 1982, with at least 135 patients treated in a similar way.1,2,8-18 Patency rates from these collected papers range between 57% and 100%, with average follow-up times of 6 to 24 months. In the current study, all the grafts functioning after 1 month have remained patent except one. Why, then, is there not more widespread application of such a powerful limb-salvage method? The skills of a vascular surgeon experienced in tibial bypass grafting surgery are sufficient to accomplish the inflow portion of this operation. The vascular surgeon must then recruit the skills of a microvascular surgeon comfortable with free tissue transfer to complete an effective team. An enthusiastic and supportive team is critical for these demanding operations. Arterial inflow source for the free muscle flaps or omentum in the current study was uniformly obtained from the distal portion of a vein bypass graft, and suturing to this soft, disease-free tissue is less technically demanding than using a small, sometimes calci-
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fied, tibial artery. Serletti et al2 also used vein grafts for inflow, but used the reperfused anterior or posterior tibial arteries for free-flap perfusion after femoralpopliteal bypass grafting if they were in continuity. In the present study, the distal vein graft anastomosis was sometimes moved closer to the ankle to avoid dependence on any native tibial artery for inflow, and this may help to explain the reliable patency observed. Perhaps the most interesting subset of patients in this report are the three who had reconstructions with end-to-end anastomoses to omental free flaps. These three patients all had soft tissue loss and were without a tibial artery sufficient to support a distal bypass grafting anastomosis. Thus, there was no new anastomosis directly to the native arterial system. Although one of these limbs was lost because of embolization into the omental flap after angiography in the postoperative period, the other two patients did well. Their split-thickness skin grafts healed, and, remarkably, the entire involved foot began to show signs of increased perfusion. This “neovascularization”19 was commented on by Cutler in a discussion of the work by Cronenwett et al.1 In that case, the neovascularization was seen after an end-to-end anastomosis with a serratus muscle flap. Neovascularization has been quantitated with both cutaneous fluorescein methods and conventional angiography, but the patients in our study were not examined with angiography because of the risks involved. Omentum has been used to relieve limb ischemia, both as a pedicle reconstruction20 and as a free flap anastomosed to patent native arteries. In fact, pedicle techniques have been developed that allow omentum still deriving its blood supply from the right gastroepiploic artery to reach across the inguinal ligament to the ankle in some patients.3 In the present study, arterial flow for the omental flap came directly from the vein bypass graft. Omentum has even been used to relieve rest pain with some success by creating a pocket for the omentum along the medial aspect of the thigh and calf. These reports also mention an increased limb perfusion remote from the omental graft.21 In the present study, all the free flaps received arterial inflow from direct anastomosis to the previously constructed venous conduit bypass grafts. One patient had a composite-sequential graft with a proximal femoropopliteal polytetrafluoroethylene (PTFE) section and a distal reversed saphenous vein to the posterior tibial artery. The free tissue flap was anastomosed distally to the venous portion. In this series, patients without venous conduit were felt not to be candidates for such an extensive operation. However, Kasablain et al have reported such a procedure, using
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PTFE for inflow with good results for as long as 3 years.22 In their case report, the tissue flap was anastomosed directly to the PTFE. Although the practice of using PTFE for inflow could be debated, it is possible that the restrictions imposed in the current study were too strict. SUMMARY Combining the two well-established surgical methods of venous conduit arterial bypass grafting and free tissue transfer creates a powerful technique for limb salvage. It enlarges the pool of patients with severe leg ischemia who have an alternative to certain leg amputation. Patients with extensive tissue loss, tibial arteries beneath infected wounds, and those without adequate tibial arterial anatomy for distal anastomosis can now be helped. In many medical centers, the organization of an enthusiastic team to perform these operations may be the main obstacle that needs to be overcome. REFERENCES 1. Cronenwett JL, McDaniel MD, Zwolak RM, Walsh DB, Schneider JR, Reus WF, et al. Limb salvage despite extensive tissue loss: Free tissue transfer combined with distal revascularization. Arch Surg 1989;124:609-15. 2. Serletti JM, Deuber MA, Guidera PM, Herrers HR, Reading G, Hurrwitz SR, et al. Atherosclerosis of the lower extremity and free-tissue reconstruction for limb salvage. Plast Reconstr Surg 1995;96:1136-44. 3. Nishimura A, Sano F, Nakanishi Y, Koshino I, Kasai Y. Omental transplantation for relief of limb ischemia. Surg Forum 1977;28:213-5. 4. Casten DF, Alday ES. Omental transfer for revascularization of the extremities. Surg Gynecol Obstet 1971;301-4. 5. Goldsmith HA. Salvage of end stage ischemic extremities by intact omentum. Surgery 1980;88,5:732-6. 6. Hoshino H, Nakayama K, Igari S, Honda K. Long-term results of omental transplantation for chronic occlusive arterial diseases. Int Surg 1983;68:47-50. 7. Gooden MA, Gentile AT, Demas CP, Berman SS, Mills JL. 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;26,4: 711-4. 8. May JW, Halls MJ, 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;75:627-41.
DISCUSSION Dr James Schuler (Chicago, Ill). This represents some truly superb results in what I think most of us would agree is a group of patients that almost certainly would have ended up with below-the-knee amputations, so I would like to say “well done.”
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9. 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;2:806-11. 10. Mimoun M, Hilligot P, Baux S. The nutrient flap: A new concept of the role of the flap and application to the salvage of arteriosclerotic lower limbs. Plast Reconstr Surg 1989;84:458-67. 11. Shenaq Sm, Dinh TA. Foot salvage in arteriosclerotic and diabetic patients by free flaps after vascular bypass: Report of two cases. Microsurgery 1989;10:310-4. 12. Shestak KC, Fitz DG, Newton ED, Swartz WM. Expanding the horizons in treatment of severe peripheral vascular disease using microsurgical techniques. Plast Reconstr Surg 1990;85:406-11. 13. Greenwald LL, Comerota AJ, Mitra A, Grosh JD, White JV. Free vascularized tissue transfer for limb salvage in peripheral vascular disease. Ann Vasc Surg 1990;4:244-54. 14. Chowdary RP, Celani VJ, Goodreau JJ, McCullough JL, McDonald KM, Nicholas GG. Free-tissue transfers for limb salvage utilizing in situ saphenous vein bypass conduit as the inflow. Plast Reconstr Surg 1991;87:529-35. 15. Sonntag BV, Murphy RX, Chernofsky MA, Chowdary RP. Microvascular steal phenomenon in lower extremity reconstruction. Ann Plast Surg 1995;34:336-40. 16. 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; 18:648-55. 17. Serletti JM, Hurwitz SR, Jones JA, Herrera HR, Reading GP, Ouriel K, et al. Extension of limb salvage by combines vascular reconstruction and adjunctive free-tissue transfer [discussion by Cronenwett JR]. J Vasc Surg 1993;18:972-80. 18. Lepantalo M, Tukiainen E. Combined vascular reconstruction and microvascular muscle flap transfer for salvage of ischemic legs with major tissue loss and wound complications. Eur J Vasc Endovasc Surg 1996;12;65-9. 19. VanLanduyt K, Monstrey S, Blondeel P, Tonnard P, Vermassen F. Revascularization by ingrowth of a free flap: Fact or fiction? Microsurgery 1996;17:417-22. 20. Hoshino S, Hamada O, Iwaya F, Takahira H, Honda K. Omental transplantation for chronic occlusive arterial diseases. Int Surg 1979;64,5:21-9. 21. Kasabian AK, Glat PM, Eidelman Y, Karp N, Giangola G. Limb salvage with microvascular free flap reconstruction using simultaneous polytetrafluoroethylene graft for inflow. Ann Plast Surg 1995;35,3:310-5. 22. Maurya D, Singhal S, Gupta HC, Hence IP, Sharma BR. Pedicled omental grafts in the revascularization of ischemic lower limbs in Buerger’s Disease. Int Surg 1985;70:253-5.
Submitted Sep 24, 1998; accepted Jan 4, 1999.
At the University of Illinois in Chicago in mid-1989, we formed a multidisciplinary team with plastic surgery. We had access at that time to two young, well-trained plastic surgeons who were experienced in microvascular technique, and we’ve been using free tissue transfer for about 10 years.
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We’ve used it in cases similar to those you’ve presented, but we’ve also used it in some other complex lower-extremity wound healing problems. Primarily, free tissue transfer has been used to achieve healing in recalcitrin or multiply recurrent venous stases ulcers. We’ve also used it in patients with combined arterial and venous ulcers. It has also been used to cover up exposed orthopedic hardware after compound fractures or with osteomyelitis. One of the ways in which we found it to be most useful is in the patient with diabetes mellitus who has extensive digital occlusive disease and plantar arch vessel occlusive disease, but who has axial patency and hemodynamically normal inflow to the ankle. In those patients, either omentum or rectus abdominous flaps can salvage feet and limbs that would otherwise be amputated. I would like to reenforce one of the things you said: forming a good working alliance with microvascular plastic surgeons is really essential. I’m convinced that we have received a lot of referrals and salvaged a lot of limbs that we would never have if not for the relationship that developed with our plastic surgeons. I have three questions. The first is, have you had any experience with performing extensive partial calcaniectomy in your patients with diabetes mellitus and then covering the defect with a flap? We’ve encountered one failure in a patient who had extensive calcaneal osteomyelitis. We applied a rectus abdominous flap, which took and stayed healed, but the patient ended up walking on a dysfunctional foot. He will probably eventually have a below-knee amputation. My second question is, have you encountered any patients in whom the femoral-to-tibial bypass grafting procedure failed and yet the flap remained viable? We encountered one patient who had a femoroperineal bypass graft. Two years after that the bypass graft occluded but the rectus abdominous free flap did not die, the wound did not recur, and, in fact, the patient has gone an additional 2 years with the femoroperineal bypass graft occluded and the wound healed. The only way we could explain this was on the basis of neovascularity, which is poorly understood. My last question is, do you have any intermediate or long-term cost-benefit analysis comparing this procedure with primary below-knee amputation? We have a number of managed care referrals, and when the medical directors or the gatekeepers find out the up-front costs of these combined procedures, they go into a state of shock. So far, they haven’t failed to continue referring patients, but each time it gets harder and harder to justify to them saving these limbs with some very large up-front costs. I would like to know if you have any data that would keep them at bay. Once again, I think this was a great paper, and I commend you. Dr Walter J. McCarthy III. Thank you. We have not done a major resection of the calcaneus, although we have had several cases in which we had to shave the calcaneus superficially. I appreciate the problems that would occur with a major deformity of that bone. About graft occlusion and flap viability, we actually have one case where we’re not sure, but, just in the last week as
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we were preparing the manuscript, it appeared that the bypass graft may have occluded yet the flap is completely viable. We’re submitting that patient to a duplex scan to see what’s going on with the graft. There are reports in the plastic surgery literature of flaps that survive after their inflow arteries occlude because of their neovascularization. In preparing the slides, I said that all the free flaps were viable, and all the grafts except one are patent. The cost-benefit analysis may be a bit shocking. The postoperative care for these patients is very extensive; they often end up coming back for additional minor operations and office visits. We share the office visits with the plastic surgeons, and patients often come back to see one of us about once a week for a period of months, until everything is healed. The benefit of keeping people out of a nursing home is extensive. These patients are able to live independently, whereas many of them would have otherwise ended up in a nursing home. We have one patient who cares for his wife, so actually we’re keeping two patients out of nursing homes by preventing his amputation. Dr Alexander D. Shepard (Detroit, Mich). I, too, congratulate you on really spectacular results, but I have to ask a question based on our results at Ford Hospital in Detroit. We, too, have had fairly extensive experience using the efforts of our plastic surgery team. Our results have not been as good long-term as your results. Now your “long term” is only slightly longer than a year. We’ve used the free flap technique in some patients with significant neuropathy and had a spectacular result, saw them back in the office with everything healed, and then, a few months later, had them come back with a recurred ulcer. Our problem basically is one, I think, of patient selection. I was wondering if you could give us some hints or guidelines as to who is really a candidate for this procedure. Which patients do you see for a first office visit and say to yourself, “there’s no way we’re going to put them through all this, through the expense of these two procedures,” and decide that a primary amputation would, in fact, be in their best interest at the outset? Dr McCarthy. I think that patients need to be potentially ambulatory. If they are not going to be able to get out of their wheelchairs, and you can anticipate that beforehand, then it’s probably better just to go ahead with a leg amputation. Second, if all the weight-bearing surface of the foot is involved, I think it might be excessive to go ahead with this sort of reconstruction. Those probably are two good guiding parameters, besides just being able to physically achieve wound healing. There are some patients who have so much infection in their ankle joint, for example, that you can anticipate not being able to get them to heal, even with good vascularized pedicle over the area. There are also patients who are seen with foot sepsis severe enough that, as in the two cases that failed primarily because of sepsis, one could anticipate that, even with a flap in place, the flap and antibiotics would not control the sepsis. Dr Joseph J. Hurley (St Louis, Mo). How high up were you able to make the omental anastomosis to your
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blood supply? Were you able to take the omental vessel anastomosis and plug it in by the popliteal and run that graft all the way down the leg? Dr McCarthy. The omentum can be pedicled and extended over a very long length. In fact, there are techniques that we didn’t use, but one can actually use to
make the anastomosis based on a patch of the gastroduodenal artery to the common femoral artery and then pedicle the omentum all the way down to the midcalf, or even to the ankle. We pedicled it to some extent, but generally began the omentum in the midcalf and then brought it down over the entire foot.
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