BACKGROUND
Peripheral arterial disease in diabetic patients is characterised predominantly by long segmental occlusion of the tibial arteries with patent segments of the dorsalis pedis artery (DPA). This allows distal bypass to the DPA using vein grafts.1 Wound complications are frequent due to the presence of foot tissue loss and oedema.2 Wound dehiscence with exposure of the DPA anastomosis is a serious postoperative complication which could lead to limb loss.3 This report describes specific measures that reduce the above risk.
TECHNIQUE
Strict leg elevation for 48 h prior to surgery is of paramount importance. Occasionally, epidural analgesia is required in patients with severe rest pain in order to achieve this. The position of the DPA is identified and marked using a hand-held Doppler, if a signal is obtainable. The incision is made 1.5 cm medial and parallel to the DPA (overlying the extensor hallucis longus tendon; Fig. 1). Dissection is continued down to the deep fascia prior to flap mobilisation to produce a lateral fasciocutaneous flap. The DPA is dissected and the bypass is performed using a reversed autologous vein graft. The graft is tunnelled laterally through the interosseous membrane. Skin closure is performed with polyglactine 3/0 without fascial approximation. Leg elevation is maintained until skin healing is achieved.
Figure 1.
Postoperative picture of a patient who underwent a right popliteal to dorsalis pedis artery bypass and amputation of a gangrenous hallux. Incision is 1.5 cm medial to the dorsalis pedis artery (solid line). The dotted line shows the pathway of the vein graft and X marks the level of the graft penetrating the interosseous membrane.
DISCUSSION
The authors have used the above measures in six patients without encountering any wound complication. In the event of wound dehiscence, the graft will still be covered and protected by the lateral fascio-cutaneous flap.
References
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