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J Reconstr Microsurg 2024; 40(05): 384-391
DOI: 10.1055/a-2181-7149
Original Article

Implications of Single-Vessel Runoff on Long-Term Outcomes of Free Tissue Transfer for Lower Extremity Reconstruction

Samuel S. Huffman 
1   Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
2   Georgetown University School of Medicine, Washington, District of Columbia
,
John D. Bovill
2   Georgetown University School of Medicine, Washington, District of Columbia
,
Karen Li 
1   Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
,
Daisy L. Spoer 
1   Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
2   Georgetown University School of Medicine, Washington, District of Columbia
,
Lauren E. Berger 
1   Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
3   Plastic and Reconstructive Surgery Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
,
Jenna C. Bekeny 
1   Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
,
Cameron M. Akbari
4   Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
,
Kenneth L. Fan
1   Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
,
Karen K. Evans
1   Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
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Abstract

Background Patients with complex lower extremity (LE) wounds and single-vessel LE runoff (1-VRO) are often considered for amputation. While more challenging, free tissue transfer (FTT) is a means for limb salvage. This study aims to demonstrate the feasibility of limb salvage with FTT in patients with 1-VRO.

Methods Patients undergoing FTT by a single surgeon between 2011 and 2021 were retrospectively reviewed. Data collected included demographics, wound characteristics, vascular status, and operative details. Patients were divided into cohorts based on 1- versus 3-VRO of tibial vessel inflow. Outcomes of interest included postoperative complications such as flap necrosis, flap success, limb salvage, and ambulatory status.

Results A total of 188 patients underwent FTT to LE, with 25 patients (13.3%) having 1-VRO. Patients with 1-VRO had a comparable prevalence of diabetes (56.0% vs. 50.0%, p = 0.569) and end-stage renal disease (8.0% vs. 3.7%, p = 0.319). Osteomyelitis was more common in the 1-VRO group (80.0% vs. 60.1%, p = 0.056). FTT donor sites and flap composition were similar between cohorts. At mean follow-up of 21.2 months (interquartile range 24.5:5.6, 30.1 months), limb salvage rates were similar between cohorts (84.0% vs. 91.4%, p = 0.241), with no significant differences in ambulatory status or mortality. Higher complication rates occurred in the 1-VRO cohort (48.0% vs. 21.5%, p = 0.004), of which partial flap necrosis was more prevalent in the 1-VRO group (8.0% vs. 1.2%, p = 0.029). There was no difference in flap success rates between groups (p = 0.805). More postflap angiograms were performed in the 1-VRO group (32.0% vs. 9.2%, p = 0.001), but there was no difference in need for repeat percutaneous endovascular intervention between groups.

Conclusion This study demonstrates that FTT reconstruction to the LE remains a reliable reconstruction option for limb salvage in patients with single-vessel supply to the LE. Reliance on advanced perioperative management and patient optimization is effective at reducing negative outcomes.

Keywords

limb salvage - amputation - free tissue transfer - end-to-side anastomosis - vessel runoff

Financial Disclosure Statement

There are no financial disclosures, commercial associations, or any other conditions posing a conflict of interest to report for any of the above authors.


Authors' Contributions

S.S.H., J.D.B., K.L., and J.C.B. conceived of the presented idea. S.S.H. developed the theory and performed the computations. S.S.H. and J.D.B. verified the analytical methods. All authors discussed the results and contributed to the final manuscript.




Publication History

Received: 11 June 2023

Accepted: 18 September 2023

Accepted Manuscript online:
26 September 2023

Article published online:
14 December 2023

© 2023. Thieme. All rights reserved.

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333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Ducic I, Rao SS, Attinger CE. Outcomes of microvascular reconstruction of single-vessel lower extremities: limb salvage versus amputation. J Reconstr Microsurg 2009; 25 (08) 475-478
    Article in Thieme ConnectPubMedGoogle Scholar
  • 2 Robbins JM, Strauss G, Aron D, Long J, Kuba J, Kaplan Y. Mortality rates and diabetic foot ulcers: is it time to communicate mortality risk to patients with diabetic foot ulceration?. J Am Podiatr Med Assoc 2008; 98 (06) 489-493
    CrossrefPubMedGoogle Scholar
  • 3 Attinger CE, Colen LB. The role of microsurgical free flaps in foot and ankle surgery. Clin Podiatr Med Surg 2000; 17 (04) 649-680
    CrossrefPubMedGoogle Scholar
  • 4 Khouri RK, Cooley BC, Kunselman AR. et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998; 102 (03) 711-721
    CrossrefPubMedGoogle Scholar
  • 5 Moran SL, Illig KA, Green RM, Serletti JM. Free-tissue transfer in patients with peripheral vascular disease: a 10-year experience. Plast Reconstr Surg 2002; 109 (03) 999-1006
    CrossrefPubMedGoogle Scholar
  • 6 Endara M, Ducic I, Attinger C. Free tissue transfer for limb salvage in high-risk patients: worth the risk. Adv Wound Care (New Rochelle) 2013; 2 (02) 63-68
    CrossrefPubMedGoogle Scholar
  • 7 Oh TS, Lee HS, Hong JP. Diabetic foot reconstruction using free flaps increases 5-year-survival rate. J Plast Reconstr Aesthet Surg 2013; 66 (02) 243-250
    CrossrefPubMedGoogle Scholar
  • 8 Kolbenschlag J, Hellmich S, Germann G, Megerle K. Free tissue transfer in patients with severe peripheral arterial disease: functional outcome in reconstruction of chronic lower extremity defects. J Reconstr Microsurg 2013; 29 (09) 607-614
    Article in Thieme ConnectPubMedGoogle Scholar
  • 9 Tukiainen E, Kallio M, Lepäntalo M. Advanced leg salvage of the critically ischemic leg with major tissue loss by vascular and plastic surgeon teamwork: long-term outcome. Ann Surg 2006; 244 (06) 949-957 , discussion 957–958
    CrossrefPubMedGoogle Scholar
  • 10 Parmaksizoglu F, Unal MB, Cansu E, Koprulu AS, Ince Y, Yurga E. Functional results of limb salvage in below-knee type III C open fractures or traumatic amputations. J Reconstr Microsurg 2012; 28 (09) 607-613
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Aravind M, Shauver MJ, Chung KC. A qualitative analysis of the decision-making process for patients with severe lower leg trauma. Plast Reconstr Surg 2010; 126 (06) 2019-2029
    CrossrefPubMedGoogle Scholar
  • 12 Orhan E, Özçağlayan Ö. Collateral circulation between angiosomes in the feet of diabetic patients. Vascular 2018; 26 (04) 432-439
    CrossrefPubMedGoogle Scholar
  • 13 Spector JA, Levine S, Levine JP. Free tissue transfer to the lower extremity distal to the zone of injury: indications and outcomes over a 25-year experience. Plast Reconstr Surg 2007; 120 (04) 952-959
    CrossrefPubMedGoogle Scholar
  • 14 Quiñones-Baldrich WJ, Kashyap VS, Taw MB. et al. Combined revascularization and microvascular free tissue transfer for limb salvage: a six-year experience. Ann Vasc Surg 2000; 14 (02) 99-104
    CrossrefPubMedGoogle Scholar
  • 15 Saddawi-Konefka D, Kim HM, Chung KC. A systematic review of outcomes and complications of reconstruction and amputation for type IIIB and IIIC fractures of the tibia. Plast Reconstr Surg 2008; 122 (06) 1796-1805
    CrossrefPubMedGoogle Scholar
  • 16 Illig KA, Moran S, Serletti J. et al. Combined free tissue transfer and infrainguinal bypass graft: an alternative to major amputation in selected patients. J Vasc Surg 2001; 33 (01) 17-23
    CrossrefPubMedGoogle Scholar
  • 17 Randon C, Jacobs B, De Ryck F, Van Landuyt K, Vermassen F. A 15-year experience with combined vascular reconstruction and free flap transfer for limb-salvage. Eur J Vasc Endovasc Surg 2009; 38 (03) 338-345
    CrossrefPubMedGoogle Scholar
  • 18 Chang CH, Huang CC, Hsu H, Lin CM, Huang SM. Editor's Choice - diabetic limb salvage with endovascular revascularisation and free tissue transfer: long-term follow up. Eur J Vasc Endovasc Surg 2019; 57 (04) 527-536
    CrossrefPubMedGoogle Scholar
  • 19 DeFazio MV, Han KD, Akbari CM, Evans KK. Free tissue transfer after targeted endovascular reperfusion for complex lower extremity reconstruction: setting the stage for success in the presence of mutlivessel disease. Ann Vasc Surg 2015; 29 (06) 1316.e7-1316.e15
    CrossrefPubMedGoogle Scholar
  • 20 Janhofer DE, Lakhiani C, Kim PJ. et al. The utility of preoperative venous testing for lower extremity flap planning in patients with lower extremity wounds. Plast Reconstr Surg 2020; 145 (01) 164e-171e
    CrossrefPubMedGoogle Scholar
  • 21 DeFazio MV, Hung RWY, Han KD, Bunting HA, Evans KK. Lower extremity flap salvage in thrombophilic patients: managing expectations in the setting of microvascular thrombosis. J Reconstr Microsurg 2016; 32 (06) 431-444
    Article in Thieme ConnectPubMedGoogle Scholar
  • 22 DeFazio MV, Economides JM, Anghel EL, Tefera EA, Evans KK. Lower extremity free tissue transfer in the setting of thrombophilia: analysis of perioperative anticoagulation protocols and predictors of flap failure. J Reconstr Microsurg 2019; 35 (04) 270-286
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Deldar R, Gupta N, Bovill JD. et al. 54. Implementation of a risk-stratified anticoagulation protocol increases free flap success in thrombophilic patients with chronic lower extremity wounds. Plast Reconstr Surg Glob Open 2022; 10 (06) 37
    CrossrefPubMedGoogle Scholar
  • 24 Bekeny JC, Zolper EG, Steinberg JS, Attinger CE, Fan KL, Evans KK. Free tissue transfer for patients with chronic lower extremity wounds. Clin Plast Surg 2021; 48 (02) 321-329
    CrossrefPubMedGoogle Scholar
  • 25 Lu J, DeFazio MV, Lakhiani C. et al. Limb salvage and functional outcomes following free tissue transfer for the treatment of recalcitrant diabetic foot ulcers. J Reconstr Microsurg 2019; 35 (02) 117-123
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Briggs SE, Banis Jr 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 (06) 806-811
    CrossrefPubMedGoogle Scholar
  • 27 Bekeny JC, Alfawaz A, Day J. et al. Indirect endovascular revascularization via collaterals: a new classification to predict wound healing and limb salvage. Ann Vasc Surg 2021; 73: 264-272
    CrossrefPubMedGoogle Scholar
  • 28 Hollenbeck ST, Woo S, Komatsu I, Erdmann D, Zenn MR, Levin LS. Longitudinal outcomes and application of the subunit principle to 165 foot and ankle free tissue transfers. Plast Reconstr Surg 2010; 125 (03) 924-934
    CrossrefPubMedGoogle Scholar
  • 29 Attinger CE, Evans KK, Bulan E, Blume P, Cooper P. Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plast Reconstr Surg 2006; 117 (7, Suppl): 261S-293S
    CrossrefPubMedGoogle Scholar
  • 30 Keller A. A new diagnostic algorithm for early prediction of vascular compromise in 208 microsurgical flaps using tissue oxygen saturation measurements. Ann Plast Surg 2009; 62 (05) 538-543
    CrossrefPubMedGoogle Scholar
  • 31 Xipoleas G, Levine E, Silver L, Koch RM, Taub PJ. A survey of microvascular protocols for lower extremity free tissue transfer II: postoperative care. Ann Plast Surg 2008; 61 (03) 280-284
    CrossrefPubMedGoogle Scholar
  • 32 Cho EH, Shammas RL, Carney MJ. et al. Muscle versus fasciocutaneous free flaps in lower extremity traumatic reconstruction: a multicenter outcomes analysis. Plast Reconstr Surg 2018; 141 (01) 191-199
    CrossrefPubMedGoogle Scholar
  • 33 Deldar R, Abu El Hawa AA, Gupta N. et al. Intensive care unit versus floor admission following lower extremity free flap surgery: is there a difference in outcomes?. Microsurgery 2022; 42 (07) 696-702
    CrossrefPubMedGoogle Scholar
  • 34 Tsai YT, Lin TS. The suitability of end-to-side microvascular anastomosis in free flap transfer for limb reconstruction. Ann Plast Surg 2012; 68 (02) 171-174
    CrossrefPubMedGoogle Scholar
  • 35 Ahmadi I, Herle P, Miller G, Hunter-Smith DJ, Leong J, Rozen WM. End-to-end versus end-to-side microvascular anastomosis: a meta-analysis of free flap outcomes. J Reconstr Microsurg 2017; 33 (06) 402-411
    Article in Thieme ConnectPubMedGoogle Scholar
  • 36 Stanziale R, Lodi M, D'Andrea E, Sammartino F, DI Luzio V. Arteriovenous fistula: end-to-end or end-to side anastomosis?. Hemodial Int 2011; 15 (01) 100-103
    CrossrefPubMedGoogle Scholar
  • 37 Black C, Fan KL, Defazio MV. et al. Limb salvage rates and functional outcomes using a longitudinal slit arteriotomy end-to-side anastomosis for limb-threatening defects in a high-risk patient population. Plast Reconstr Surg 2020; 145 (05) 1302-1312
    CrossrefPubMedGoogle Scholar
  • 38 Black CK, Kotha VS, Fan KL, Ragothaman K, Attinger CE, Evans KK. Pedicled and free tissue transfers. Clin Podiatr Med Surg 2019; 36 (03) 441-455
    CrossrefPubMedGoogle Scholar
  • 39 DeFazio MV, Fan KL, Evans KK. Greater saphenous vein-patch interposition to facilitate flow-sparing microanastomosis of calcified arteries in the distal lower extremity. Plast Reconstr Surg 2019; 144 (02) 340e-341e
    CrossrefPubMedGoogle Scholar
  • 40 Shestak KC, Hendricks DL, Webster MW. Indirect revascularization of the lower extremity by means of microvascular free-muscle flap–a preliminary report. J Vasc Surg 1990; 12 (05) 581-585
    PubMedGoogle Scholar
  • 41 Treiser MD, Miles MR, Albino FP, Giladi AM, Katz RD, Higgins JP. Long-term patency and fluid dynamics of recipient artery after end-to-side anastomosis for free tissue transfer. Plast Reconstr Surg 2021; 148 (05) 800e-803e
    CrossrefPubMedGoogle Scholar