Distal revascularization and microvascular

Transcription

1 Distal revascularization and microvascular free tissue transfer: An alternative to amputation in ischemic lesions of the lower extremity Susan E. Briggs, M.D., Joseph C. Banis, Jr., M.D., Hermann Kaebnick, M.D., Bruce Silverberg, M.D., and Robert D. Acland, M.D., Louisville, Ky. Most lower extremity amputations result from compfications of diabetes and arteriosclerotic occlusive diseases below the inguinal ligament. Improved limb salvage has been achieved by an aggressive approach to distal revascularization in the severely ischemic lower extremity. There remains, however, a high incidence of amputation resulting from progession of the ulceration or gangrene into deeper and less well-vascularized tissues, such as tendon and bone. Even in the nonischemic extremity, such wounds rarely heal without flap coverage. Microvascular free tissue transfers promote healing by providing coverage with healthy, nondiseased, well-vasoalarized tissue for these diffioalt defects. Successful free flap transfer requires a high-pressure recipient inflow vessel. In contrast to individuals with nonarteriosclerotie lesions, many individuals with nonhealing ischemie lesions have no acceptable artery demonstrated on high-resolution angiography to serve as a recipient vessel. Limb salvage has been achieved in four candidates for amputation utilizing distal revascularization followed by free tissue transfer coverage of the ischemic lower leg defects. (J VAsc SuRG 1985; 2: ) In the United States 30,000 to 50,000 lower extremity amputations are performed yearly. Ninetyfive percent of these amputations result from complications of diabetes and arteriosclerotic occlusive disease below the inguinal ligament. ~-3 Infrainguinal arteriosclerotic occlusive disease may result in ischemic rest pain, ulceration, or gangrene. Improved limb salvage has been achieved by an aggressive approach to distal revascularization in the severely ischemic lower extremity? -9 Femorotibial and femoroperoneal saphenous vein bypass grafts have been performed with much success to facilitate healing of skin ulcerations, skin grafts, local pedicle flaps, and digital amputations in ischemic lesions of the lower extremity. Despite such aggressive approaches to revascularization in the lower extremity, many ischemic le- From the Department of Surgery, Universi~ of Louisville School of Medicine. Presented at the Ninth Annual Meeting of the Southern Association for Vascular Surgery, West Palm Beach Gardens, Fla., )ran. 30-Feb. 2, Reprint requests: Susan E. Briggs, M.D., Department of Surgery, University of Louisville School of Medicine, Ambulatory Care Building, Louisville, KY sions result in amputation. Causes of lower extremity amputations include nonreconstructible occlusive lesions, failed arterial reconstructions, and gangrenous lesions extending into deeper and less well-vascularized tissues (i.e., tendon and bone).9,1 Conventional methods of lower extremity wound management, such as skin grafts and local pedicle flaps, are usua[! r-', not successful in the treatment of such ischemic lesions. Microvascular free tissue transfer has provided an alternative to amputation in the management of these difficult wounds. 1H3 Microvascular free tissue transfers ("free flaps") have been used with significant success in the reconstruction of congenital defects, traumatic wounds with exposed and disrupted tendon and bone, and soft tissue, muscle, and osseous defects following radical cancer surgery and burn deformities. H-~8 The major criterion for consideration of free tissue transfers in the treatment of such lesions is the presence of an acceptable recipient vessel. Unlike individuals with nonarteriosclerotic lesions of the lower extremity, many individuals with lesions from arteriosclerotic occlusive disease and diabetes often have no recipient vessel to serve as the conduit for the free tissue transfer. We present our experience with an organized

2 Volume 2 Number 6 November 1985 Distal revascularization and microvascular free tissue transfer 807 C' Fig. 1A-B. A, Arteriogram after revascularization demonstrating junction of saphenous vein bypass to posterior tibial artery, with single-vessel runoff to pedal arch. B, Transmetatarsal amputation defect of left foot, with unhealthy bacterially colonized granulation tissue over subjacent tendon and bone. protocol for limb salvage in patients with severe lower extremity ischemic lesions including tendon and bone. MATERIAL AND METHODS Four patients, ages 69 to 80 years, who presented with ischemic ulcerations of the lower extremity in- ~rolving tendon and bone, underwent distal revascularization and free tissue transfer for limb salvage (Table I). Three of the four patients were diabetic. All patients underwent preoperative arteriography often combined with digital subtraction angiography for evaluation of the distal vascular anatomy and pedal arch. Intraoperative angiography was performed following the distal revascularization. Free tissue transfers were performed as a separate operative procedure 2 to 3 weeks following the bypass. Postoperative assessment included clinical evaluation of wound stability and functional status and noninvasive Doppler pulse volume recordings (PVRs) every 6 months for assessment of vascular status. CASE REPORTS Case 1. A 63-year-old diabetic man presented with a 7 x 9 cm ulceration of the right heel with exposed Achilles tendon and calcaneus. Pulse examination revealed a 2/2 Table I. Patient profile Case Ischemic lesion Bypass Variety of flap 1 Heel (tendon/bone) AT Rectus abdominis 2 Toes (tendon/bone) PT Radial forearm 3 Ankle (tendon) AT Scapular 4 Ankle (tendon) PT Scapular AT = anterior tibial; PT = posterior tibial. right femoral pulse with no distal pulses palpable. An anterior tibial pulse was present at Doppler examination. The ankle-brachial index was Angiography demonstrated occlusion of the superficial femoral artery with reconstitution of the anterior tibial artery in the distal third of the leg. The posterior tibial and peroneal arteries were occluded. The patient underwent a right common femoral artery-to-distal anterior tibial artery reversed saphenous vein bypass graft. Two weeks later, he underwent free tissue transfer reconstruction of the remaining necrotic heel defect utilizing a rectus abdominis muscle flap covered with skin graft. The native anterior tibial artery distal to the saphenous vein graft was utilized as the recipient vessel for the free tissue transfer. The postoperative course was uneventful except for the slow wound healing typically demonstrated in the diabetic patient. The patient began walking 2 months postoperatively and has remained healed and symptom-free for 9 months.

3 808 Briggs et al. Journal of VASCULAR SURGERY Fig. 1C-E. C, Pattern of radial forearm skin flap vascularized by radial artery and vein, with potential for cutaneous sensor}~ reconstruction by nerve anastomosis. D, Flap elevated, with artery and vein pedicle demonstrated superiorly, and lateral antebrachial cutaneous nerve demonstrated inferiorly. E, Reconstructed defect in early postoperative period, with photo-plethysmography monitoring device in place. Case 2. A 62-year-old diabetic woman presented with rest pain and dry gangrene of the toes of the left foot extending proximal to the level of the metatarsal heads. Pulse examination demonstrated a 2/2 left femoral pulse with no palpable distal pulses. A posterior tibial pulse was present at Doppler examination. The ankle-brachial index was Angiography demonstrated occlusion of the superficial femoral artery with reconstitution of the distal posterior tibial artery at the midcalf level. The patient underwent a left common femoral artery-to-distal posterior tibial artery reversed saphenous vein bypass graft. Ten days following revascularization, she underwent open transmetatarsal amputation of the gangrenous digits. Three weeks later, she underwent free tissue transfer reconstruction of her transmetatarsal amputation defect with the use of a radial forearm sensate skin flap. The revascularized native posterior tibial artery posterior to the medial malleolus was utilized as the recipient vessel for the free tissue transfer. Because of the significant underlying cardiopulmonary disease, all operative procedures were performed with the patient under regional and epidural blocks. Her postoperative course was marked by an absence of any cardiopulmonary complications, satisfactory wound healing, and return to progressively ambulatory status at "', month postoperatively (Fig. 1). ~ Case 3. An 80-year-old nondiabetic man came to the hospital complaining of rest pain and with a 3 x 6 cm ulceration of the posterior ankle overlying and involying the tendo Achillis. Pulse examination demonstrated 2/2 left femoral pulse, 1/2 left popliteal pulse, and no palpable distal pulses. A left anterior tibial pulse was demonstrated at Doppler examination. Angiography demonstrated a diseased but patent superficial femoral artery with occlusion of the posterior tibial and anterior tibial arteries in the midcalf. The peroncal artery was patent and the anterior tibial artery reconstituted at the level of the ankle. The ankle-brachial index was The patient underwent a common femoral artery-to-distal anterior tibial artery reversed saphenous vein bypass graft. Three weeks later, he underwent free tissue transfer reconstruction of the gangrenous lesion of the tendo Achillis with a scapular skin flap. The recipient vessel for the free tissue transfer was the

4 Volume 2 Number 6 November 1985 Distal revascularization and microvascular free tissue transfer 809 ) Fig. 2A-C. A, Necrotic defect (3 x 8 cm) of left posterior ankle involving tendo Achillis. B, Design of left scapular free flap showing relationship to scapular tip, and schematic demonstration of vascular supply. C, Healed reconstruction 3 months postoperatively. distal portion of the autogenous vein bypass graft. A postoperative arteriogram demonstrated patency of the distal bypass and free flap pedicle vessel. The patient is without symptoms and fully ambulatory with no wound breakdown 1 year postoperatively. Case 4. A 7J-year-old diabetic man presented with a 3 x 8 cm necrotic ulceration of the left posterior heel in. eluding the Achilles tendon. Pulse examination demongtrated a 2/2 left femoral pulse with no palpable distal pulses. A posterior tibial pulse was demonstrated at Doppler examination. The anlde-brachial index was An arteriogram demonstrated severe trifurcation disease with proximal posterior and anterior tibial artery occlusions. The peroneal artery was severely diseased with multiple stenotic areas. Reconstitution of the posterior tibial artery was noted at the ankle level. The patient underwent a reversed saphenous vein bypass graft from the common femoral artery to the distal posterior tibial artery at the medial malleolus. Two weeks later, the patient underwent free flap reconstruction of the necrotic posterior ankle defect with a scapular skin flap. The recipient vessel for the free flap transfer was the distal portion of the saphenous vein bypass graft. A postoperative arteriogram demonstrated patency of the distal bypass and the free flap pedicle vessel. The patient is without symptoms and fully ambulatory with no recurrence of ulceration at 1.5 years postoperatively (Fig. 2). Fig. 2 D. Arteriogram after reconstruction demonstrating saphenous vein bypass to distal posterior tibial artery, with flee flap pedicle arising from vein bypass graft noted just to left of vein bypass, proceeding distally to supply flap tissue.

5 810 Briggs et al. Journal of VASCULAR SURGERY DISCUSSION Successful revascularization is essential for wound healing and the avoidance of amputation in many lower extremity ischemic lesions. Distal arterial revascularization procedures with autogenous saphenous vein appear to offer the best long-term patency in limb salvage procedures involving the lower extremity. 6'8 Despite aggressive approaches to revascularization for limb salvage, including reconstructions to the level of the dorsalis pedis artery and posterior tibial artery below the ankle, 20% to 40% of patients will require major amputations. 3"6"8 In patients with potentially reconstructible lesions, failed arterial reconstructions and ischemic lesions extending to tendon and bone remain the leading causes of amputation. Despite bypass of the lower extremity occlusive disease, ischemic lesions involving the tendo Achillis, calcaneus, and midfoot are associated with particularly high rates of major amputations. Our experience indicates that the ultimate "limb procedure" need not be amputation in all cases of ischemic lesions involving tendon and bone. In the four patients described, the distal arterial bypass provided revascularization of the ischemic limb as well as the necessary conduit of blood supply for a free tissue transfer to reconstruct the severe ischemic lesions. This plan of management allowed us to avoid amputation in these patients with complex ischemicdiabetic wounds. Microsurgery is the technique of performing routine surgical procedures on otherwise inopcrably small structures with the aid of the surgical microscope. Microvascular free tissue transfer is the technique of transplanting healthy, well-vascularized, undamaged tissue ("flap") with its dominant vascular pedicle from one anatomic region to another using the surgical microscope to reconnect precisely the tiny vessels that provide blood supply to these flaps. Microvascular free tissue transfer is proving superior to other methods of wound management in providing coverage for difficult wounds of the lower extremity, particularly those lesions involving the distal third of the leg and foot where other local flaps are unavailable or unreliable, and those lesions extending into avascular or poorly vascularized tissues, such as tendon and bone. TM Free tissue transfer has the distinct advantage of freely allowing movement of skin, muscle, and bone as desired to achieve optimal functional and aesthetic results. More than 60 potential donor sites are available for free tissue transfers, thereby allowing wide flexibility in the choice of a donor site. 13 The ability to achieve coverage O f the ischemic defect with well-vascularized donor ti~sue from a site remote from the ischemic lesion prevents further local tissue disruption and complications with wound healing. Microvascular free flaps have an independent, well-defined blood supply of their own that does not rely on the recipient bed for vascular ingrowth, an advantage in patients with ischemic occlusive disease of the lower extremity. TM The prerequisites for successful free tissue transfer include an acceptable recipient inflow vessel. Few cases have been reported utilizing free tissue transfers in patients with arteriosclerotic occlusive disease of the lower extremityf 6q9 The limiting factor in selecting a recipient vessel for free tissue transfer in patients with peripheral vascular disease is the lowflow state in the arteriosclerotic vessel rather than the vessel wall disease itself. As opposed to individud'~ with nonarteriosclerotic lesions, radiologic assessment of the lower extremity vascular anatomy is essential when free tissue transfers are considered for reconstruction of ischemic lesions. Routine angiography often combined with intra-artcrial digital subtraction angiography has proved valuable in the selection of candidates for free tissue transfer. 2 ax Distal revascularization may provide a suitable recipient vessel in two ways in patients with no acceptable recipient vessel for free tissue transfer. Following revascularization, either the native vessel distal to the arterial bypass or the arterial bypass graft itself may be used as the recipient vessel for the free tissue transfer. The use of supplemental vein grafts to provide additional length of the vascular pedicle of the free flap and a tension-free vascular anastomosis affords the surgeon considerable freedom in the selection of suitable recipient arteries and vei~ ~- outside the zone of injury. Vein grafts of up to 40 cm in length are used successfully in free flap transfers. 11 One-vessel runoff, as present in three of these patients, does not preclude the successful use of free tissue transfer. Steal phenomena have not been documented in free tissue transfer. The flow rate in free flaps (2 to 10 ml/min) is limited by the vascular bed of the flap and is well below the potential inflow of the recipient vessel. The length of operative time necessary for performance of both the revascularization and the free tissue transfer may be a disadvantage in patients with cardiopulmonary disease. The operative risks of reconstruction vs. amputation must be critically and realistically assessed in all patients. In the four reported cases, distal revascularization was performed at a separate time from the free tissue transfer to allow

6 Volume 2 Number 6 November 1985 Distal revascularization and microvascular free tissue transfer 811 for evaluation of early technical difficulties and to avoid prolonged anesthesia. Careful preoperative planning allows a choice of regional anesthetic administration as an alternative to general anesthesia, both for the revascularization and "free flap" reconstruction. The most serious technical complication of "free flap" surgery is the potential for postoperative anastomotic thrombosis with resultant necrosis of the flap. 21'22 The success rate in experienced hands approaches 95%. 21'22 CONCLUSIONS Distal revascularization and free tissue transfer reconstruction offer a viable alternative to amputation in selected patients with ischemic lesions of the... :gwer extremity involving tendon and bone. The technique of utilizing the distal autogenous vein bypass graft as the recipient vessel for the free tissue transfer in the management of ischemic lesions of the lower extremity has not been previously reported. This preliminary experience suggests a broad potential for microvascular adjuncts in the treatment of patients with complex ischemic lesions of the lower extremity following successful revascularization. REFERENCES 1. LoGerfo FW, Coffman JD. Vascular and microvascular disease of the foot in diabetes. N Engl J Med 1984; 311: Barrier HB, Kaiser GC, Willman VL. Blood flow in the diabetic leg. Circulation 1971; 43: Stoney RJ. Ultimate salvage for the patient with limb-threatening ischemia. Realistic goals and surgical considerations. Am [1 Surg 1978; 136: Reichle FA, Martinson MW, Rankin KP. Infrapopliteal ar- '. terial reconstruction in the severely ischemic lower extremity. Ann Surg 1980; 191: Dardik H, Ibrahim IM, Dardik II. The role of the peroneal artery for limb salvage. Ann Surg 1979; 189: Yeager RA, Hobson RW, Jamil Z, Lynch TG, Lee BC, Jain K. Differential patency and limb salvage for polytetrafluoroethylene and autogenous saphenous vein in severe lower extremity ischemia. Surgery 1982; 91: Veith FJ, Gupta SK, Samson RH, Scher LA, Fell SC, Weiss P, Janko G, Flores SW, Rifldn H, Bernstein G, Haimovici H, Gliedman ML, Sprayregen S. Progress in limb salvage with reconstructive arterial surgery combined with new or improved adjunctive procedures. Ann Surg 1981; 194: Bergan JJ, Veith FJ, Bernhard VM, Yao JST, Flinn WR, Gupta SK, Scher LA, Samson RH, Towne JB. Randomization of autogenous vein and polytetrafluoroethylene grafts in femoral-distal reconstruction. Surgery 1982; 92: O'Mara CS, Flinn WR, Neiman HL, Bergan JJ, Yao JST. Correlation of foot arterial anatomy with early tibia[ bypass patency. Surgery 1981; 89: Hobson RW, Lynch TG, Jamil Z, Karanfilian RG, Lee BC, Padberg Jr FT, Long JB. Results of revascularization and amputation in severe lower extremity ischemia: A five-year clinical experience, J VAsc SUR6 1985; 2: Shaw WW. Microvascular free flaps. The first decade. Clin Hast Surg 1983; 10: Serafin D, Voci VE. Reconstruction of the lower extremity. Microsurgical composite tissue transplantation. Clin Hast Surg 1983; 10: Harii K. Microvascular free flaps for skin coverage. Indications and selections of donor sites. Clin Hast Surg 1983; 10: May Jr JW, Gallico III GG, Lukash FN. Microvascular transfer of free tissue for closure of bone wounds of the distal lower extremity. N Engl J Med 1982; 306: Takami H, Takahashi S, Ando M. Microvascular free musculocutaneous flaps for the treatment of avulsion injuries of the lower leg. J Trauma 1983; 23: Dabb RW, David RW. Latissirnus dorsi free flaps in the elderly: An alternative to below&nee amputation. Hast Reconstr Surg 1984; 73: Ohtsuka H, Kamiishi H, Shioya N. Successful free flap transfers in two diabetics. Hast Reconstr Surg 1978; 61: Ohtsuka H, Kamiishi H, Saito H, Ito M, Shioya N. Successful free flap transfers with diseased recipient vessels. Br J Hast Surg 1976; 29: van Gdder PA, Klopper PJ. Microvascular surgery and diseased vessels. Surgery 1981; 90: Flanigan DP, Williams LR, Keifer T, Schuler JJ, Behrend AJ. Prebypass operative arteriography. Surgery 1982; 92: Tumipseed WD, Detmer DE, Berkoff HA, Acher CW, Crummy AB, Belzer FO. Intra-arterial digital angiography: A new diagnostic method for determining limb salvage bypass candidates. Surgery 1982; 92: Harrison DH, GiBing M, Mott G. Methods of assessing the viability of free flap transfer during the postoperative period. Clin Hast Surg 1983; 10:21-36.