Results of combined vascular reconstruction and free flap transfer for limb salvage in patients with critical limb ischemia Alexander Meyer, MD, Katja.

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Presentation transcript:

Results of combined vascular reconstruction and free flap transfer for limb salvage in patients with critical limb ischemia Alexander Meyer, MD, Katja Goller, Raymund E. Horch, MD, Justus P. Beier, MD, Christian D. Taeger, MD, Andreas Arkudas, MD, Werner Lang, MD, FEBVS Journal of Vascular Surgery Volume 61, Issue 5, Pages 1239-1248 (May 2015) DOI: 10.1016/j.jvs.2014.12.005 Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 1 Preoperative and postoperative images of patients with heavy tissue loss due to critical limb ischemia (CLI). a, Patient with heel necrosis and deep malleolar ulceration. Exposure of flexor hallucis tendon. b, The same patient 5 months after two-stage vascular reconstruction with vein bypass graft and free tissue transfer by means of radialis forearm flap. c, Radical débridement of an ischemic forefoot gangrene. Large area of exposure of the talus bone. d, Situs after arteriovenous (AV) loop construction and two-stage defect coverage using rectus abdominis muscle free flap. No limitations in ambulation with adjusted custom-made orthopedic shoes. Journal of Vascular Surgery 2015 61, 1239-1248DOI: (10.1016/j.jvs.2014.12.005) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 2 Postoperative angiogram of arteriovenous (AV) loop in a patient with lower leg ulceration. a, Construction of AV loop (arrow) before free flap transfer due to single-vessel vascularization of lower leg. b, Postoperative patency control. A rectus abdominis free flap has been connected after apical loop separation in an end-to-end fashion. The arrow indicates the anastomosis of flap artery to arterial limb of the AV loop. c, Homogeneous perfusion of rectus abdominis flap. Journal of Vascular Surgery 2015 61, 1239-1248DOI: (10.1016/j.jvs.2014.12.005) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 3 Postoperative angiogram and clinical outcome of radialis forearm flap connected to pedal bypass graft. a, The large arrow indicates pedal vein bypass, with anastomosis to anterior tibial artery. The small arrow shows the flap artery anastomosed in end-to-side fashion to the bypass graft. b, Postoperative clinical outcome 1 year after surgery. Journal of Vascular Surgery 2015 61, 1239-1248DOI: (10.1016/j.jvs.2014.12.005) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 4 Treatment of patient with malleolar ulceration with arteriovenous (AV) loop construction and radialis free flap transfer. Intraoperative situs. a, Popliteal-tibial AV loop (ipsilateral great saphenous vein reversed to fibular vein). The radialis forearm flap artery and vein are connected in an end-to-end fashion to the separated AV loop. b, View through surgical microscope after completion of arterial and venous end-to-end anastomoses. Journal of Vascular Surgery 2015 61, 1239-1248DOI: (10.1016/j.jvs.2014.12.005) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 5 Kaplan-Meier curve for overall patient survival. Journal of Vascular Surgery 2015 61, 1239-1248DOI: (10.1016/j.jvs.2014.12.005) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 6 Kaplan-Meier curve for combined amputation-free survival. Journal of Vascular Surgery 2015 61, 1239-1248DOI: (10.1016/j.jvs.2014.12.005) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 7 Major below-the-knee amputation with vital latissimus dorsi free flap. Excellent tissue coverage of amputation stump. Journal of Vascular Surgery 2015 61, 1239-1248DOI: (10.1016/j.jvs.2014.12.005) Copyright © 2015 Society for Vascular Surgery Terms and Conditions