What is the Impact of Infrapopliteal Endovascular Intervention on Free Flap Survival in Diabetic Foot Reconstruction?

Overview

Journal J Orthop Surg Res

Publisher Biomed Central

Specialty Orthopedics

Date 2021 Jan 12

PMID 33430921

Citations 1

Authors

Duy Quang Thai

Dong Hwan Lee

Woo Beom Lee

Hyung Min Hahn

Il Jae Lee

Affiliations

Soon will be listed here.

Abstract

Background: The combination of endovascular intervention and microvascular free flap transfer has been effectively used for chronic ischemic wounds of lower limb. The aim of this study was to determine the influence of angioplasty on free flap survival in diabetic foot ulcer reconstruction.

Methods: A retrospective research was conducted for 46 diabetic patients with chronic ulcer of the foot. All patients underwent free flap reconstruction because of their non-healing wound with tendon or bone exposure. Patient's demography, clinical data related to vascular status, vascular intervention, and free flap transfer procedure were collected. Flap survival rate was compared between the group with severe arterial stenosis group and non-severe stenosis group. It was also compared among groups with different revascularization results.

Results: The average age of patients was 56.2 ± 10.8 years. There were 14 (30.4%) men and 32 (69.6%) women. Of 46 patients, 23 (50%) had severe infrapopliteal arterial stenosis. All 23 patients underwent endovascular intervention. Their final results of the pedal arch were type 1 in 13 patients, type 2A in 7 patients, type 2B in 2 patients, and type 3 in 1 patient. Total flap necrosis was found in 5 (10.9%) cases, marginal necrosis in 4 (8.7%) cases, and wound dehiscence in 4 (8.7%) cases. There was no significant difference in flap loss between severe arterial stenosis patients and non-severe arterial stenosis patients. In the severe arterial stenosis group, after endovascular intervention, patients with type 1 of pedal arch had a significantly lower rate of total flap necrosis than others. There was no association between the use of revascularized recipient artery and flap survival.

Conclusions: Our study revealed that the quality of pedal arch was crucial for free flap survival. Thus, PTA should aim to re-establish a complete pedal arch to increase wound healing rate and flap success.

Citing Articles

[Research advances on the application of free flaps in repairing diabetic foot ulcers].

Jian Y, Wei Z, Chen W, Zhang Y, Tang M, Zhong Y Zhonghua Shao Shang Yu Chuang Mian Xiu Fu Za Zhi. 2023; 39(4):376-380.

PMID: 37805742 PMC: 11630216. DOI: 10.3760/cma.j.cn501225-20221216-00539.

[Clinical effects of antibiotic bone cement combined with free anterolateral thigh flap in sequential treatment of diabetic foot ulcer].

Chen W, Chang S, Zhou J, Zhang F, Yang C, Nie K Zhonghua Shao Shang Yu Chuang Mian Xiu Fu Za Zhi. 2023; 39(4):319-324.

PMID: 37805733 PMC: 11630293. DOI: 10.3760/cma.j.cn501225-20220628-00267.

Factors affecting the outcome of lower extremity osteomyelitis treated with microvascular free flaps: an analysis of 65 patients.

Thai D, Jung Y, Hahn H, Lee I J Orthop Surg Res. 2021; 16(1):535.

PMID: 34452615 PMC: 8393737. DOI: 10.1186/s13018-021-02686-x.

References

Randon C, Vermassen F, Jacobs B, De Ryck F, Van Landuyt K, Taes Y . Outcome of arterial reconstruction and free-flap coverage in diabetic foot ulcers: long-term results. World J Surg. 2009; 34(1):177-84. DOI: 10.1007/s00268-009-0250-9. View

Mishra A, Jain N, Bhagwat A . CT Angiography of Peripheral Arterial Disease by 256-Slice Scanner: Accuracy, Advantages and Disadvantages Compared to Digital Subtraction Angiography. Vasc Endovascular Surg. 2017; 51(5):247-254. DOI: 10.1177/1538574417698906. View

De Luccia N, Sassaki P, Durazzo A, Sandri G, Kikuchi M, Hirata C . Limb salvage using bypass to the perigeniculate arteries. Eur J Vasc Endovasc Surg. 2011; 42(3):374-8. DOI: 10.1016/j.ejvs.2011.04.024. View

Vermassen F, Van Landuyt K . Combined vascular reconstruction and free flap transfer in diabetic arterial disease. Diabetes Metab Res Rev. 2000; 16 Suppl 1:S33-6. DOI: 10.1002/1520-7560(200009/10)16:1+<::aid-dmrr111>3.0.co;2-y. View

Kudo T, Chandra F, Ahn S . The effectiveness of percutaneous transluminal angioplasty for the treatment of critical limb ischemia: a 10-year experience. J Vasc Surg. 2005; 41(3):423-35. DOI: 10.1016/j.jvs.2004.11.041. View

Moulik P, Mtonga R, Gill G . Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Diabetes Care. 2003; 26(2):491-4. DOI: 10.2337/diacare.26.2.491. View

Briggs S, Banis Jr J, Kaebnick H, Silverberg B, Acland R . Distal revascularization and microvascular free tissue transfer: an alternative to amputation in ischemic lesions of the lower extremity. J Vasc Surg. 1985; 2(6):806-11. DOI: 10.1067/mva.1985.avs0020806. View

Kallio M, Vikatmaa P, Kantonen I, Lepantalo M, Venermo M, Tukiainen E . Strategies for free flap transfer and revascularisation with long-term outcome in the treatment of large diabetic foot lesions. Eur J Vasc Endovasc Surg. 2015; 50(2):223-30. DOI: 10.1016/j.ejvs.2015.04.004. View

Patel S, Biasi L, Paraskevopoulos I, Silickas J, Lea T, Diamantopoulos A . Comparison of angioplasty and bypass surgery for critical limb ischaemia in patients with infrapopliteal peripheral artery disease. Br J Surg. 2016; 103(13):1815-1822. DOI: 10.1002/bjs.10292. View

10.

Fitzgerald OConnor E, Vesely M, Holt P, Jones K, Thompson M, Hinchliffe R . A systematic review of free tissue transfer in the management of non-traumatic lower extremity wounds in patients with diabetes. Eur J Vasc Endovasc Surg. 2010; 41(3):391-9. DOI: 10.1016/j.ejvs.2010.11.013. View

11.

Hashimoto I, Abe Y, Morimoto A, Kashiwagi K, Goishi K, Nakanishi H . Limb salvage and vascular augmentation by microsurgical free flap transfer for treatment of neuropathic diabetic foot ulcers. J Med Invest. 2014; 61(3-4):325-32. DOI: 10.2152/jmi.61.325. View

12.

Kim J, Lee Y . A study of the survival factors of free flap in older diabetic patients. J Reconstr Microsurg. 2007; 23(7):373-80. DOI: 10.1055/s-2007-992345. View

13.

Bordianu A, Bobirca F, Patrascu T . Skin Grafting in the Treatment of Diabetic Foot Soft Tissue Defects. Chirurgia (Bucur). 2018; 113(5):644-650. DOI: 10.21614/chirurgia.113.5.644. View

14.

Oh T, Lee H, Hong J . Diabetic foot reconstruction using free flaps increases 5-year-survival rate. J Plast Reconstr Aesthet Surg. 2012; 66(2):243-50. DOI: 10.1016/j.bjps.2012.09.024. View

15.

Hahn H, Jeong Y, Hong Y, Won J, Lim S, Kim J . Use of revascularized artery as a recipient in microvascular reconstruction of the lower leg: An analysis of 62 consecutive free flap transfers. J Plast Reconstr Aesthet Surg. 2017; 70(5):606-617. DOI: 10.1016/j.bjps.2017.01.010. View

16.

Huang C, Chang C, Hsu H, Mark Chiu C, Lin C, Lee J . Endovascular revascularization and free tissue transfer for lower limb salvage. J Plast Reconstr Aesthet Surg. 2014; 67(10):1407-14. DOI: 10.1016/j.bjps.2014.05.026. View

17.

Rashid H, Slim H, Zayed H, Huang D, Wilkins C, Evans D . The impact of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and infrapopliteal bypass outcome. J Vasc Surg. 2013; 57(5):1219-26. DOI: 10.1016/j.jvs.2012.10.129. View

18.

Hong J, Oh T . An algorithm for limb salvage for diabetic foot ulcers. Clin Plast Surg. 2012; 39(3):341-52. DOI: 10.1016/j.cps.2012.05.004. View

19.

Igari K, Kudo T, Toyofuku T, Jibiki M, Inoue Y, Tanaka K . Combined arterial reconstruction and free tissue transfer for patients with critical limb ischemia. Ann Vasc Dis. 2014; 6(4):706-10. PMC: 3866359. DOI: 10.3400/avd.oa.13-00052. View

20.

Arvela E, Venermo M, Soderstrom M, Korhonen M, Halmesmaki K, Alback A . Infrainguinal percutaneous transluminal angioplasty or bypass surgery in patients aged 80 years and older with critical leg ischaemia. Br J Surg. 2011; 98(4):518-26. DOI: 10.1002/bjs.7390. View