Free Tissue Transfer Using End-to-side Arterial Anastomosis for Limb Salvage in Patients With Lower Extremity Arterial Disease

Abstract

Free tissue transfer (FTT) is an invaluable component of functional limb salvage in patients with large lower extremity wounds for whom limb amputation is the only alternative. The traditional FTT technique involves a donor vessel anastomosed in an end-to-end fashion to the recipient vessel. End-to-side anastomosis has rarely been utilized due to perceived technical difficulty with vessel size mismatch. In patients with single vessel runoff, an end-to-end anastomosis is contraindicated. Given our focus on limb salvage in patients with LEAD, we have almost exclusively utilized the end-to-side arterial anastomosis, and herein present our experience. A retrospective review of all patients undergoing FTT at a single institution from 2012 to 2020 was performed. All patients underwent preoperative arteriogram, and LEAD was defined as abnormal tibial runoff of any degree. All patients with evidence of LEAD were included for this analysis. Our operative approach has been previously described and involves a longitudinal arteriotomy in the inflow vessel. The flap donor artery is then sutured from heel to toe in an interrupted fashion under microscopic visualization. There were 141 free flaps performed during this period using an end-to-side anastomosis; 67 patients had evidence of LEAD by arteriography. Average age was 59 years (range, 19-87 years); 54% had diabetes; 18% had one vessel runoff to the foot; 58% had two vessel runoff to the foot; and 19% required preoperative endovascular intervention. Technical success of FTT was achieved in 97% of patients. At 30 days, the limb salvage rate was 96%. No patients died in the perioperative period. At a mean follow-up of 1.1 years, the overall limb salvage rate was 79%. Free flap survival rate was 92%. 83% of patients were ambulatory independently or with an assistive device on most recent follow-up. FTT in patients with LEAD and large wounds is a reasonable approach to limb salvage. End-to-side anastomosis is a feasible technique that allows free flap survival with preservation of distal flow.