Interdisciplinary lower extremity reconstruction in peripheral artery disease with AV-loops and latissimus dorsi flaps

TL;DR

This study shows that using AV-loops and latissimus dorsi flaps can safely cover leg tissue defects in patients with poor blood flow from peripheral artery disease.

Contribution

The study introduces a reliable surgical method for lower leg reconstruction in patients with compromised vascular conditions.

Findings

The procedure had a low flap loss rate even in severe vascular compromise.

Permanent patency of the pedicle vessel is not essential for flap survival in PAOD.

Most patients reported high satisfaction despite the physical and psychological stress of the procedure.

Abstract

Extensive soft tissue defects of the lower leg can be effectively addressed by transplantation of various free microvascular flaps. A fundamental requirement for successful free microvascular flap coverage is the availability of adequate recipient arteries and veins. In cases where vascular conditions are compromised, such as in peripheral artery disease (PAD), achieving effective defect coverage through free microvascular flap transplantation poses significant challenges. One potential treatment option is the creation of an arteriovenous (AV) - loop to facilitate the attachment of a free flap.

Our study comprises patients receiving AV-loops with free latissimus dorsi flaps between 2019 and 2021. A retrospective review was performed of all patients who underwent this operative procedure with a minimum follow-up time of 3 years. We conducted pre- and intraoperative flow measurements with ultrasound. Flap survival, autonomisation and patient satisfaction was analyzed clinically, with thermography and the Freiburg Index of Patient Satisfaction (FIPS). We focus on identifying which patients benefit from this approach, as well as exploring limitations related to the severity of peripheral arterial occlusive disease (PAOD).

Our study showed that this procedure can be used to cover defects safely and with a low flap loss rate, even in highly compromised vascular situations. It was also shown that even in PAOD, permanent patency of the pedicle vessel is not essential for the flap. In this study, with its associated limitations, we were unable to establish a reliable correlation between preoperative and intraoperative flow measurements and flap loss in the two-stage procedure we chose. Despite the high physical and psychological stress on the individual patients, the majority were satisfied with the procedure and the result.

Defect coverage of the lower extremity using a loop and free muscle flap is a safe, reliable procedure with a high patient satisfaction.

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