Epiploic Bypass Flap: A New Method of Limb Salvage. Anatomic Basis and Clinical Application

Abstract

The incidence of critical limb ischemia increases with the aging of the population. Two-thirds of patients with critical limb ischemia present with trophic disorders. Revascularization decreases the rate of amputation. Infected wounds with exposure of the tendons, bones, or points of articulation cannot heal in spite of bridging and local debridement. Surgery associated with a distal venous bypass or recanalization and a free flap makes it possible to cover major tissue loss and offers a hemodynamic advantage by increasing the flow of the bypass, thanks to the vascular bed added by the flap. It is a complex surgery because of the multiplicity of anastomoses on the same arterial axis, with a risk of thrombosis and complications related to the venous autograft. To mitigate these disadvantages, we propose a new surgical method based on the use of a single anatomic unit, the epiploic bypass flap (BF), based on the gastroepiploic artery (GEA) as the inflow for a bypass and a free flap. The objective of this work was to analyze the anatomic feasibility of an epiploic BF and to determine its limits. One hundred anatomic preparations were conducted with a measure of the internal and external diameters and the lengths of GEA and its branches and a radiograph after injection of a radiopaque product. A first clinical application was carried out. According to the data, our study confirms the anatomic feasibility of a BF. The average available length of GEA is 245 mm (range: 210-280 mm). The average proximal diameter is 3 mm, and the distal diameter is 1.5 mm. The most distal epiploic branch that feeds the bypass is approximately 180 mm (range: 161-195 mm) of the origin of the GEA. The anatomic unit based on the GEA provides an arterial graft that is relatively long and a large flap that is both malleable and resistant to infection. Epiploic BF is a surgical technique that allows for distal revascularization and a simultaneous cover of the limb extremity. This technique can be useful in patients requiring a distal revascularization associated with a cutaneous cover.