Arterialized Vein Bypass Grafts as Recipient Vessel for Free Tissue Transfer in Coverage of Diabetic Foot Ulcers Complicated by Critical Limb Ischemia
Ryu Tran, MS1; ZoŽ K. Haffner, BS2; Robert Slamin, MD2; Cameron Akbari, MD3; Karen K. Evans, MD2
1Georgetown University School of Medicine; Washington, District of Columbia. 2Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia. 3Department of Vascular Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia
Objectives: Limb salvage options are limited in diabetic patients with critical limb ischemia. Soft tissue coverage remains technically demanding with limited recipient vessels for free tissue transfer (FTT). These factors make revascularization alone challenging. When open bypass revascularization is possible, venous bypass graft (VBG) is optimal and functions as a recipient vessel for staged FTT.
Methods: The authors present two cases utilizing a combination approach of staged VBG revascularization followed by FTT with anastomosis to the VBG resulting in successful limb preservation.
Results: Case one: 75-year-old male with type 2 diabetes mellitus, atrial fibrillation, and ischemic cardiomyopathy presented with an abscess in the left pre-Achilles space. The wound required multiple debridements to clear MSSA colonization resulting in a 120cm2 posterolateral wound. Preoperative angiogram revealed occluded anterior (AT) and posterior tibial (PT) arteries. Saphenous VBG, popliteal-to-distal-PT, followed an unsuccessful recanalization. FTT of contralateral latissimus dorsi muscle with end-to-side anastomosis to VBG provided coverage. This was complicated by candida infection and successfully treated with debridement and hyperbaric oxygen therapy. 11-months postoperatively, he ambulates well in a DH shoe and VBG remains patent.Case two: 67-year-old male with diabetic neuropathy, end-stage renal disease, and peripheral vascular disease (PVD) presented with 5-month history of a 108cm2 non-healing wound on lateral right foot. He had undergone a right popliteal-to-dorsalis-pedis VBG 3-months prior and hyperbaric oxygen therapy without improvement of his wound. Preoperative angiogram demonstrated occlusion of proximal AT and distal PT, and patent VBG. Preoperatively, the VBG was chosen as the recipient vessel. 2cm of the VBG was exposed allowing for end-to-side anastomosis of an ipsilateral-anterior-lateral thigh free flap for successful coverage. Patient experienced no complications and is weight bearing in an Arizona brace 4-months postoperatively.
Conclusion: FTT to a native vessel has limited application in severe PVD patients because early vascular compromise threatens flap survival. In both presented cases, VBG alone was insufficient to treat their non-healing wounds and preoperative angiogram revealed dismal options for FTT reconstruction. However, previous VBG provided an operable vessel for FTT anastomosis. The combination of VBG and FTT proved to be ideal for successful limb preservation by providing vascularized tissue to previously ischemic angiosomes ensuring optimal wound healing capacity. VBG is advantageous to native arterial grafts and its combination with FTT likely increases graft patency and flap survival. We demonstrate that end-to-side anastomosis to a VBG is a viable option in these highly comorbid patients with favorable flap outcomes.
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