4/18/2015 Introduction • The epidemic of diabetes and ageing of our population ensures critical limb PUT YOUR BEST FOOT ischemia will continue to grow. FORWARD • Estimated costs $150-300 billion (2010 data): range depends on data being used Bala Ramanan, MBBS and cost counted. 1 st year vascular surgery fellow • Exposed bones and/or tendons make limb salvage more difficult. HPI Physical Examination • 57 year old woman • Lower extremity pulse exam: Right lower extremity- all pulses were • Chronic non-healing wound on the left foot. palpable. • Left lower extremity- femoral pulse palpable, popliteal pulse non-palpable, • Over the course of 1 year she underwent a series of Pedal pulses non-palpable. Peroneal signal was heard at the distal ankle. vascular and wound treatments at an OSH for the left foot • including an atherectomy of the left popliteal and anterior Foot exam: Left open TMA with superficial necrosis of the distal end of the wound, plantar skin viable, normal sensation in the foot and good ankle tibial arteries and a popliteal stent. range of movement, no venous stasis changes in leg. • HBO therapy but no improvement. • Non-invasive vascular studies: • TMA of the left foot which then necrosed and was slowly • ABI: Right-0.92, Left-0.10. worsening. • TcPO2 on the plantar surface of the Left foot- 12 mmHg. • Advised BKA. • Ultrasound- Greater saphenous vein in the left leg measured >3mm • SH: 40 pack year smoker –stopped 6 years ago. throughout its length, no reflux, no deep vein thrombosis. 1
4/18/2015 Given the normal right lower extremity Is this limb salvageable? what most likely represents her diagnosis? 40% A. YES? 54% A. Atherosclerosis 30% B. NO? 46% 23% B. Embolism C. Trash foot following 7% atherectomy D. Thrombosed popliteal artery s m i s . aneurysm s . . o i . . l . r r o h a e b t c l a l m a s g e o E n t r i e i l w p h o o t A l p l o d f e t s o o o b f m h ? ? s o S O a r h E N r Y T T 2
4/18/2015 Imaging- Angiogram What are the options for management? A. Below knee amputation B. Patient should be referred to a no revascularization option: cell-based or 46% gene therapy trial C. Pedal access and recanalization of the anterior tibial and peroneal arteries 19% 19% 15% D. SFA to peroneal bypass with soft tissue coverage 0% E. Anterograde access and recanalization n o . . . . . . . . i . . i w . . of the anterior tibial artery t e l d a r a t r s n u e n s a a p f a e c p s m r e s y a e r e d b c b c e n l e d a a a e n l e k u s n o s o d w a h e r c e r o s g t c p o e l a n o r B e l e a t i d t t A n a e F A P P S 3
4/18/2015 Case Management • Left SFA-Peroneal Bypass with non-reversed greater saphenous vein (Vascular surgery). • Left foot debridement of subcutaneous tissue, muscles, tendons and metatarsals were debrided back to the base (Podiatry). • Right rectus abdominis free flap to left TMA Stump (Plastic Surgery)- inferior epigastric artery and vein were anastomosed to a jump graft off the SFA-peroneal bypass and anterior tibial vena commitante. • Split thickness skin graft placed over the muscle flap. Postoperative course • Uneventful recovery in the hospital. • Flap was closely monitored. • Discharged to rehabilitation facility on POD 18 on aspirin. • 1 week later the patient noted a change in the color of the flap and was readmitted. 4
4/18/2015 • She had no history of trauma to the flap or symptoms. • On examination: • The flap appeared dark with loss of about 30-40% of the skin graft. • It had dopplerable arterial and venous signals. • Ultrasound showed a patent bypass graft and no DVT in the leg. Case Management What should be done? • Underwent debridement of the flap and was found to have A. Systemic anticoagulation. a viable flap with an intramuscular hematoma. B. Conservative management with wound 56% vac. • No further events postoperatively. C. Amputation. D. Apply leaches. • Activity was gradually increased. E. OR for exploration of the flap and 16% 16% • Got another split thickness skin graft and was discharged excision of necrotic tissue. 6% 3% 3% home. 0% F. OR for exploration and revision of . . . anastomosis. . n s . p n . . . . o e . . a o e h e . i e l i m t c h f t a r a a t e l e t e d e u g u f • On follow up in clinic, she had viable muscle flap, warm l o n r g a p f y n a a n m l w p o n o a m A p i o e G. New free flap. c t i A a i N t t n e r a o a v r i l o t p foot, 100% take of her skin graft c l i a x p m v x e r e e e r t o s r s n f o y o R f S C O R O 5
4/18/2015 Biomechanical issues with a TMA • Increased pressure in the forefoot- leads to ulcer development. • Equinovarus is the most common complication. • Parabola of the metatarsals may not be maintained leading to increased pressure over the elongated metatarsal. • MANAGEMENT: Custom shoes and regular follow up. • Tendoachilles lengthening or gastrocnemius recession for equinovarus deformity. Workup of a failing free flap FLAP FACTS • Arterial duplex of the bypass graft to evaluate the • Free muscle flap increases the outflow for lower extremity bypass. inflow- angiogram if issue with the bypass. • Neovascularization from surrounding ischemic tissues by collaterals occurs as soon as 3 weeks and the flap can survive even if the bypass occludes. • Venous ultrasound for deep venous thrombosis. • Free flap can serve as the sole outflow for a bypass graft in patients with unacceptable or no runoff. • Examination of the flap for temperature, color and • Contraindications: ESRD, uncontrolled diabetes, current smoker. arterial and venous signals. Relative- history of graft thrombosis. 6
4/18/2015 FLAP FAILURES Conclusions • Flap thrombosis- occurs in a bimodal pattern. Usually within 1 st 48 hours or after 1 week. • Combined lower extremity bypass with complex foot reconstruction with free tissue transfer is an • Reasons- arterial or venous thrombosis (more common), option for patients with good foot function and pressure on the flap. large soft-tissue defects. • Management – • All free flap patients are started on aspirin, subcutaneous • These procedures are associated with high rate of heparin immediately postop. • If trouble with anastomosis during surgery-some surgeons early perioperative revisions of both the bypass and use low dose heparin drip. the free flap. • If flap thrombosis suspected- exploration in the OR within 6 hours of onset. 7
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