SLR - August 2023 - Linsey Andrews, DPM
Title: Use of Recanalized Vessels for Diabetic Foot Reconstruction: Pushing the Boundaries of Reconstruction in a Vasculopathic Lower ExtremityReference: Suh, Hyunsuk P. MD, PhD1,2; Kedar, Daniel J. MD3; Lee, Yeon Hoon MD1; Lee, Pil Hyung MD, PhD2,4; Lee, Seung-Whan MD, PhD2,3; Hong, Joon Pio MD, PhD, MMM1,2. Use of Recanalized Vessels for Diabetic Foot Reconstruction: Pushing the Boundaries of Reconstruction in a Vasculopathic Lower Extremity. Plastic and Reconstructive Surgery March 2023.151(3):p 485e-494e
Level of Evidence: Level III Retrospective Study
Scientific Literature Review
Reviewed By: Linsey Andrews, DPM
Residency Program: MedStar Washington Hospital Center
Podiatric Relevance: Foot complications are the leading cause of hospital admission, amputation and mortality amongst diabetics. As foot and ankle surgeons, our goal is limb salvage. Surgical options available for reconstruction include skin grafts, local or pedicled flaps and free-tissue transfer. Free-flap reconstruction provides supplementary blood flow to ischemic zones, contributes to venous drainage and may promote faster inosculation making it ideal for limb salvage. A critical issue for this salvage option is vascularity. Many diabetics will develop peripheral arterial disease as part of their disease process. For those that develop critical limb ischemia, nearly half will require revascularization. Maximization of flow through angioplasties or bypass is critical for both successful flap coverage as well as chance for limb salvage. Recanalization allows surgeons to reestablish flow from a partially or completely occluded vessel after angioplasty. With successful recanalization there is an increase in suitable recipient vessels thus giving surgeons more options. These recanalized vessels are not without issue. This study aimed to report the results of using recanalized arteries for diabetic foot reconstruction as well as analyzing the outcomes.
Methods: A level III retrospective study of patients who underwent diabetic foot reconstruction with free flaps combined with successful percutaneous transluminal angioplasty (PTA) from February 2010 to February of 2016 was completed. 62 patients were divided into three groups: group 1 included patients with nonoccluded vessels as recipient while receiving PTA on other arteries (n=11), group 2 included patients with recanalized artery after PTA for partial occlusions (n= 30), and group 3 included patients with recanalized artery after PTA for complete occlusions (n=21). Data was compared between groups using Pearson chi-square test or Fisher test. Kaplan-Meier curve was used to determine amputation-free survival rates.
Results: The demographic characteristics of the three groups showed no statistically significant differences except for the number of affected angiosomes, which was greater in group 3 than 1 or 2. In terms of flap failure, there was no difference between patients with no occlusion versus partial occlusions. There was a statistically significant difference between these groups and those with complete occlusions, however. Based on the Kaplan-Meier survival analysis, group 1 had a 90.9% patient survival and limb salvage rate at 1 and 3 years. Group 2 was 89.8% (1 year) and 86.3% (3& 5 years), group 3 was 76.2% (1,3, and 5 years). Although there were differences between each of the groups, it was not enough to reach statistical significance.
Conclusions: This study demonstrates that free-flap combined with recanalization may offer patients with even the most severe vessel disease a chance for limb salvage. It is important to note that this study only followed patients for 5 years following intervention, therefore long-term survival and salvage rates are not known. Despite this, it is clear that podiatrists should consider a multi-specialty approach in terms of limb salvage in order to decrease morbidity and mortality rates among their patients.