title: Combination of Vascular Intervention Surgery and Free Tissue Transfer for Critical Diabetic Limb Salvage.
abstract: BACKGROUND
  Complex, nontraumatic diabetic foot ulcers with peripheral vascular compromise often lead to extensive lower-limb amputation. The aim of this study is to determine the outcome of combined vascular intervention and free tissue transfer for critical diabetic limb salvage.
  
  
  METHODS
  A total of 26 consecutive diabetic patients with 28 legs with diabetic foot ulcers who underwent limb salvage with a combination of revascularization (bypass surgery or endovascular angioplasty) and free flap transfers were reviewed. There were 14 male and 12 female patients. The average age was 58.8 years (range, 35-85 years). Amputation-free survival and complete wound healing were defined as the primary endpoints. All preoperative and postoperative data were retrospectively analyzed.
  
  
  RESULTS
  Thirty flaps were used for reconstruction in 28 legs, including 21 free anterolateral thigh (ALT) perforator flaps, 3 ALT myocutaneous flaps, 5 gracilis muscle flaps, and 1 latissimus dorsi muscle flap. All flaps used end-to-side anastomoses for the recipient artery and end-to-end anastomoses for the recipient vein. The overall flap success rate was 90% (27/30). Two flaps failed completely because of severe arteriosclerosis, which resulted in anastomosed vessel thrombosis. New flaps were applied in both cases after debridement and trimming of necrotic tissue. One flap failed because of restenosis and inadequate perfusion combined with severe infection, resulting in pedicle thrombosis. A below-knee amputation was subsequently performed. Seven flaps exhibited a partial loss, including 6 ALT perforator flaps and 1 latissimus dorsi flap, because of inadequate margin perfusion. After debridement, the flap revision and wound care, 5 flaps healed uneventfully without additional intervention. The remaining 2 ALT perforator flaps required debridement with a skin graft. The limb-salvage rates were 92.8% after 1 year and 89.2% after 5 years.
  
  
  CONCLUSIONS
  The combination of peripheral arterial intervention and free tissue transfer resulted in successful wound healing and limb salvage instead of amputation in select diabetic patients with difficult-to-heal wounds.
authors.affiliation: From the *Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital; †Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine; ‡Faculty of Medicine, College of Medicine, Kaohsiung Medical University; and §Department of Biological Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan.
authors.forename: Chieh
authors.initials: C
authors.lastname: Chou
authors.forename: Pao-Jen
authors.initials: PJ
authors.lastname: Kuo
authors.forename: Yen-Chou
authors.initials: YC
authors.lastname: Chen
authors.forename: Shu-Hung
authors.initials: SH
authors.lastname: Huang
authors.forename: Chih-Hau
authors.initials: CH
authors.lastname: Chang
authors.forename: Yi-Chia
authors.initials: YC
authors.lastname: Wu
authors.forename: Su-Shin
authors.initials: SS
authors.lastname: Lee
authors.forename: Cheng-Sheng
authors.initials: CS
authors.lastname: Lai
authors.forename: Sin-Daw
authors.initials: SD
authors.lastname: Lin
authors.forename: Kao-Ping
authors.initials: KP
authors.lastname: Chang
authors.forename: Yur-Ren
authors.initials: YR
authors.lastname: Kuo
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017719:Diabetic Foot / Q000601:surgery*; D057510:Endovascular Procedures; D005260:Female; D005500:Follow-Up Studies; D058752:Free Tissue Flaps / Q000637:transplantation*; D006801:Humans; D023821:Limb Salvage / Q000379:methods*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods*