An improvised arterial end‐to‐side anastomosis from flap to arterialised vein graft in the diabetic foot

Dear Editors,

In patients with peripheral vascular disease, chronic wounds with bone exposure and underlying osteomyelitis pose significant challenges to both vascular and plastic surgeons. These patients usually undergo amputation although there is increasing evidence that limb salvage is achievable with staged or concomitant vascular bypass and free flap reconstruction.

A previously independent, obese (body mass index = 35·2), 56‐year‐old insulin‐dependent diabetic (IDDM) male was referred for wound management in October 2011, after developing a calcaneal pressure ulcer on his heel, following a coronary artery bypass graft (CABG). At the time of admission, a 6 × 7 cm sloughing calcaneal ulcer and non‐healing wound were noted along the length of the harvested right long saphenous vein. Angiography of the lower limb showed occlusion of the distal popliteal artery with only collateral flow distally (Figure 1).

Figure 1.

Intraoperative photograph demonstrating the arterialised vein graft and site of anterolateral thigh flap anastomosis.

A radical debridement was performed in conjunction with the vascular surgeons, leaving gentamicin‐impregnated polymethyl methacrylate (PMMA) beads in situ, and negative pressure wound therapy (NPWT) for temporary wound coverage. Bone biopsy cultures showed presence of Staphylococcus aureus and Pseudomonas aeruginosa that were sensitive to ceftazidime therapy.

The contralateral long saphenous vein was harvested intraoperatively and anastomosed from the proximal popliteal artery to the posterior tibial artery. Satisfactory flow was achieved without complications (Figures 2 and 3). A contralateral anterolateral thigh (ALT) flap was raised and after unsuccessful attempts to anastomose the flap to the terminal branches of the posterior tibial artery, because of atheromatous plaques, an end‐to‐side anastomosis of the autologous vein graft was performed to the flap. One vena comitans of the flap was anastomosed end‐to‐end with the posterior tibial vein. The surgery lasted 7·5 hours.

Figure 2.

Photograph demonstrating the reconstructed heel post‐operatively.

Figure 3.

Angiogram demonstrating pre and post‐operative vessels of the lower leg – arrow 1 demonstrating the multiple collaterals formed secondary to a popliteal artery obstruction and arrow 2 demonstrating the arterialised vein graft in situ feeding the anastomosed free flap. Note the improved blood supply to calcaneal region post flap insertion.

There were no postoperative flap complications although a haematoma was evacuated from the saphenous vein donor site. The total hospital stay was 18 days. The patient began weight bearing at 3 weeks, and was fully mobile by 6 weeks. All wounds were healed at the 4‐month follow‐up.

Up to 15% of diabetic patients will develop foot ulcers during their lifetime and those with foot ulcers have a 15% increased mortality compared with those with intact feet over a 3‐year period. The statistical data for patients undergoing amputation in the setting of critical ischaemia is bleak; 50% mortality rate in the first 5 years post amputation, 15–30% contralateral limb amputation 2 years after amputation and 28% of amputations fail to heal 1.

In these cases, bypass flap surgery offers an opportunity to avoid amputation 2, 3. The unique shock absorbing design of the heel region poses a distinct reconstructive challenge 4, 5. Both myocutaneous flaps, for example gracilis and rectus abdominis, and fasciocutaneous flaps like example ALT, radial forearm and scapular, have reported good functional outcomes 6, 7. The transplantation of low vascular resistance tissue has demonstrated prolonged bypass graft survival, although microvascular steal syndrome has also been reported 1.

A combined vascular‐plastic surgical reconstruction, of one or two stage, offers the opportunity for limb salvage in diabetic patients with non‐traumatic lower extremity wounds. There are operative advantages to a one‐step procedure namely the recipient vessels are already exposed. Overall this population experiences a higher incidence of flap failure and perioperative complications.

Disclaimer

The authors state that they have seen and agreed to the submitted version of the paper, and bear responsibility for it. All who have been acknowledged as contributors or as providers of personal communications have agreed to their inclusion. The material is original and has been neither published elsewhere nor submitted for publication. If accepted, the paper will not be published elsewhere in the same or similar form, in English or in any other language, without written consent of the copyright holder.

Zaher Jandali, MD1, Nizar Bafiq, MD MRCSI2, Charles
Yuen Yung Loh, MBBS MSc MRCS, Plastic Surgery
Registrar3 & Thanassi Athanassopoulos, MA MBBS
FRCS(Plast), Plastic Surgery Registrar3
1Department of Plastic, Aesthetic and Reconstructive surgery
Asklepios Klinik Wandsbek
Hamburg, Germany
2Department of Plastic Surgery
Cork University Hospital
Ireland, Ireland
3Department of Plastic Surgery
Ninewells Hospital
Dundee, UK
chloh_yy@hotmail.com