Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67, 1407e1414

Endovascular revascularization and free

tissue transfer for lower limb salvage
Chieh-Chi Huang a,b, Chien-Hwa Chang c, Honda Hsu a,b,*,
Chih-Hung Mark Chiu a, Chih-Ming Lin a, Jiunn-Tat Lee d,
Sou-Hsin Chien b,e

a
Division of Plastic Surgery, Tzu Chi Dalin General Hospital, Chiayi County, Taiwan
b
School of Medicine, Tzu Chi University, Hualien County, Taiwan
c
Division of Cardiovascular Surgery, Tzu Chi Dalin General Hospital, Chiayi County, Taiwan
d
Division of Plastic Surgery, Tzu Chi Hualien General Hospital, Hualien, Taiwan
e
Division of Plastic Surgery, Tzu Chi Taichung General Hospital, Taichung, Taiwan

Received 22 March 2014; accepted 15 May 2014

KEYWORDS Summary Combined bypass surgery with free flap reconstruction is an established method
Endovascular; for lower limb salvage. But the success of the combination of endovascular revascularization
Angioplasty; together with free tissue transfer has so far not been well established. A retrospective review
Free tissue transfer; of all patients who had undergone endovascular revascularization and reconstructed with free
Lower limb salvage tissue transfer for lower limb salvage at Tzu Chi Dalin General Hospital between 2008 and 2012
was performed. A total of 26 legs underwent limb salvage in 24 patients. There were 10 male
and 14 female patients. Their average age was 71.4 years. The average time interval between
endovascular intervention and free tissue transfer was 8 days. There was 100% flap survival but
partial flap necrosis was seen in three patients. A high rate of wound infection was seen in
eight patients, all requiring further debridement. The total limb salvage rate at 1-year
follow-up was 96% and 92% at the 2-year follow-up. In conclusion, the success rate of lower
limb salvage using a combination of endovascular revascularization and free tissue reconstruc-
tion is comparable to using a combination of bypass surgery and free tissue transfer. It is asso-
ciated with a high flap success rate and a high limb salvage rate. It provides physicians with a
further treatment option in the management of ischemic lower limbs with extended tissue
loss.
ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

* Corresponding author. Division of Plastic Surgery, Tzu Chi Dalin General Hospital, Chiayi County, Taiwan. Tel.: þ886 928637812.
E-mail address: hondahsu@yahoo.com.tw (H. Hsu).

http://dx.doi.org/10.1016/j.bjps.2014.05.026
1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
1408 C.-C. Huang et al.

Introduction
Diabetic patients with critical limb ischemia and extended
soft-tissue defects are a complex problem that requires
multidisciplinary involvement. The reconstructive surgeon,
the vascular surgeon, and the endovascular physicians
frequently face these conditions. Revascularization will
lead to an improvement in wound healing. But when there
is bone or tendon exposure, limb salvage is not possible
without further flap coverage. Numerous studies with re-
gard to combining vascular distal bypass surgery and free
tissue reconstruction of the lower limb have been published
since it was first described by Briggs et al., in 1985.1e6 Since
then, this technique has been widely used for limb salvage,
becoming common practice in many reconstruction and
vascular centers. However, with the introduction of endo-
vascular therapy in the treatment for peripheral arterial
occlusive disease, it has, in many centers, superseded
distal bypass as the first-line treatment in the critically
ischemic limb. Numerous centers’ current ischemic limb
management algorithms now propose an “endovascular
first” intervention, using percutaneous transluminal angio-
plasty (PTA) as the primary treatment of choice.7e11 The
combination of endovascular revascularization and free
flap reconstruction has not been well established. We
reviewed our patients in the past 5 years who had under-
gone endovascular treatment in the lower leg, followed by
or simultaneously reconstructed with a free flap. The aim
of this study was to assess the safety and efficacy of this
combination of treatment.
Materials and methods
All patients who had undergone endovascular angioplasty
followed by or simultaneously reconstructed with free tis-
sue transfer for lower limb salvage between April 2008 and
April 2012 at Dalin Tzu Chi General Hospital were included
in this study.
Our treatment protocol for all patients with an open
wound of the foot is a thorough assessment of the risk
factors for peripheral vascular disease such as diabetes
mellitus, hypertension, hypercholesterolemia, and smok-
ing. The peripheral pulses are then palpated. If they are
absent, ankleebrachial index (ABI) and pulsed volume
recording (PVR) are measured and recorded. If the readings
are suggestive of peripheral vascular disease, the vascular
surgeon is consulted and angiogram together with angio-
plasty is performed at the same time if necessary. Once
revascularization is successful, debridement of the diabetic
foot can be performed often during the same anesthetic
period. The patient are usually placed on aspirin, clopi-
dogrel and cilostazol at this time. If bone and/or tendon
exposure is seen, the condition is discussed with the patient
and his family and free tissue transfer reconstruction is
undertaken. If there were no bone or tendon exposure or if
the exposed defect is small, then skin graft is performed or

Table 1 Patient demographics.

Pt Age Sex Defect location Defect size Endovascular Interval between
procedure surgery (days)
1a 58 M L forefoot 20  10 cm Angioplasty 10
2b 82 F L forefoot 15  8 cm Angioplasty 9
3 61 F R dorsal foot and ankle 6  5 cm Angioplasty 7
4 64 M L forefoot 7  6 cm Angioplasty 6
5 80 M L heel 9  4 cm Angioplasty 8
6 83 F R heel 3  3 cm Angioplasty 12
7 74 M R dorsal foot 4  4 cm Angioplasty 6
8 70 F L plantar foot 4  4 cm Angioplasty 10
9 89 F L forefoot 5  4 cm Stent SFA 14
10 59 F R dorsal and plantar foot 10  5 cm Angioplasty 8
11 60 F L plantar foot 11  6 cm Angioplasty 10
12 80 F L plantar foot 12  7 cm Angioplasty 10
13 73 F R forefoot 12  8 cm Angioplasty 5
14 60 F L dorsal foot 15  10 cm Angioplasty 4
15b 84 F R forefoot 10  7 cm Angioplasty 6
16 81 F L dorsal foot 10  8 cm Stent SFA 5
17 86 M L plantar foot 15  7 cm Angioplasty 7
18 69 M R heel 10  7 cm Angioplasty 10
19 51 F L plantar foot 12  4 cm Angioplasty 8
20 67 M L heel 17  8 cm Angioplasty 7
21 70 M L dorsal foot 13  6 cm Angioplasty 6
22 78 F R heel 6  7 cm Angioplasty 7
23 63 M R plantar foot 8  6 cm Stent iliac and SFA 9
24 83 M L forefoot 6  3 cm Angioplasty 5
25 60 F L ankle 15  6 cm Angioplasty 10
26a 61 M R dorsal foot 20  10 cm Angioplasty 14
a
Means patients 1 and 26 are the same patient.
b
Means patients 2 and 15 are the same patient.
Endovascular revascularization for lower limb salvage 1409

alternatively healing by secondary intention is permitted. Results

Demographic data and medical history were obtained by
retrospective chart review.
Data that were collected included: age, gender, co-
morbid illnesses, defect location, defect size, number of
endovascular procedures, TASC (TransAtlantic InterSociety
Consensus) level, type of flap, length of surgery, flap sur-
vival, and success of limb salvage. It was also noted when
the patient had undergone a previous or simultaneous PTA
(Table 1). Immediate limb salvage rate (<30 days) was
noted and the patients were followed up to determine if
further limb amputation occurred (>30 days) (Table 2). The
patient’s perioperative and postoperative course were
carefully followed up and their surgical and medical com-
plications were tabulated (Table 3). The perioperative
mortality rate was also recorded (see Table 4).
A total of 26 legs underwent limb salvage in 24 patients.
There were 10 male and 14 female patients. Their average
age was 71.4 years (range 51e89). All of the patients had
diabetes mellitus with TASC lesions C to D of the infrapo-
pliteal vessels. The average time interval between endo-
vascular intervention and free tissue transfer was 8 days
(range 4e14 days) (Table 1). Stenting of the superficial
femoral artery was performed in three cases with addi-
tional stenting of the iliac vessel in one case. In one of the
patients, angioplasty was performed on a thrombosed
bypass vessel. All of the patients had Wagner classification
3e4 diabetic foot with bone and tendon exposure. All of the
defects were reconstructed with either vastus lateralis
muscle or rectus femoris muscle flap together with skin

Table 2 Vascular intervention, recipient vessels, and limb salvage rate.

Pt Endovascular procedure Number of TASC level Recipient vessels Flap survival Limb salvage
endovascular (infrapopliteal)
procedures
1a Angioplasty 1 C DP and concomitant vein Yes Yes
2b Angioplasty 1 D Bypassed graft and ATA Yes Yes
comitant vein
3 Angioplasty 1 D DP and concomitant vein Yes Yes
4 Angioplasty 1 C DP and concomitant vein Yes Yes
(But BKA 21 months later)
5 Angioplasty 1 D DP and GSV Yes Yes
6 Angioplasty 1 C DP and GSV Yes Yes
7 Angioplasty 1 C DP and GSV Yes Yes
8 Angioplasty 1 DP and GSV Yes Yes
9 Angioplasty and 1 D DP and GSV Yes Yes
stent SFA
10 Angioplasty 1 D DP and concomitant vein Yes Yes
11 Angioplasty 1 D DP and GSV Yes Yes
12 Angioplasty 1 D ATA and concomitant vein Yes Yes
13 Angioplasty 1 D DP and concomitant vein Yes Yes
14 Angioplasty 1 D PTA and concomitant vein Yes Yes
15b Angioplasty 2 D DP and concomitant vein Yes Yes
(Right AKA 6 months later)
16 Angioplasty and 1 D ATA and concomitant vein Yes
Stent SFA
17 Angioplasty 1 D PTA and concomitant vein Yes Yes
18 Angioplasty 1D PTA and Yes Yes
concomitant vein
19 Angioplasty 1 D DP and concomitant vein Yes Yes
20 Angioplasty 1 D PTA and concomitant vein Yes Yes
21 Angioplasty 1 D ATA and concomitant vein Yes Yes
22 Angioplasty 1 C PTA and concomitant vein Yes Yes
23 Angioplasty, stent 1 D DP and concomitant vein Yes Yes
iliac, and SFA
24 Angioplasty 1D DP and Yes Yes
concomitant vein
25 Angioplasty 1 D DP and concomitant vein Yes Yes
26a Angioplasty 1 D DP and concomitant vein Yes Yes
Pt Z patient, TASC Z TransAtlantic InterSociety Consensus, DP Z dorsalis pedis, ATA Z anterior tibial artery, PTA Z posterior tibial
artery, GSV Z greater saphenous vein, SFA Z superficial femoral artery, BKA Z below-knee amputation, AKA Z above knee amputation.
Patient 1 and 26, as well as patient 2 and 15, are the same patient.
a
Means patients 1 and 26 are the same patient.
b
Means patients 2 and 15 are the same patient.
1410 C.-C. Huang et al.

Table 3 Perioperative complications and mortality.

Complications Number
Overall patients with complications 14
Overall medical complications 2
Death 1
Pneumonia 1
Overall surgical complications 12
Partial flap loss 3
Wound infection 7
Marginal skin graft loss 1
Thrombosis 1

grafting (Table 2). There was 100% flap survival, but partial
flap necrosis was seen in three patients. A high rate of
wound infection was seen in eight patients, all requiring
further debridement. One patient died during the periop-
erative period. No further deaths were seen. One patient
developed aspiration pneumonia and was treated success-
fully with antibiotics.
The immediate total limb salvage rate was 100%. In one
patient, further limb amputation was required 6 months Figure 1 KaplaneMeier analysis shows an overall limb sur-
later due to acute thrombosis of her lower leg vessels. One vival of 92%.
patient underwent below-knee amputation 21 months later
due to deep-seated foot infection. The total limb salvage
rate at 1-year follow-up was 96% and was 92% at 2-year A free vastus lateralis muscle flap with skin graft was per-
follow-up. KaplaneMeier analysis estimated a limb survival formed for reconstruction. There was good survival of the
of 92% (Figure 1). No further deaths or other morbidities flap and skin graft at 1-year follow-up (Figure 4aec).
were seen in their follow-up.
Discussion
Illustrative case
As plastic and reconstructive surgeons involved in the
treatment of critical lower limb ischemia with complex
A 63-year-old old man with a history of diabetes mellitus
soft-tissue defects, we need to keep up with constant ad-
and hypertension presented with progressive gangrene of
vances and innovations in the other disciplines of surgery.
the right fifth toe and foot (Figure 2). Clinically the pe-
Previously in ischemic limbs with limited tissue loss,
ripheral pulses were absent. ABI was recorded as 0.7. The
revascularization with pedal bypass surgery was the first
vascular surgeon was consulted. Angiograms showed diffuse
line of treatment. However, with the introduction of
multi-segmental lesions in the superficial femoral artery
and below the knee arteries. Poor flow was seen in the foot.
Angioplasty was performed with stenting of the superficial
femoral artery (Figure 3aef). Once revascularization was
achieved; fourth and fifth toe open amputation as well as
debridement of the lateral foot was done at the same time.

Table 4 Prevalence of comorbid illnesses.

Comorbid illness Number of
patients
Diabetes mellitus 25
Hypertension 14
Coronary artery disease 6
Cerebrovascular accident 4
End-stage renal failure on hemodialysis 6
Rheumatoid arthritis 3
Previous contralateral limb major amputation 2
Gout 1 Figure 2 A 63-year-old old man with diabetes mellitus and
Dementia 2 hypertension presented with gangrenous changes of the right
fifth toe, with extension of the infection into the fourth toe.
Endovascular revascularization for lower limb salvage
Figure 3 aefDiffuse multi-segmental lesions were seen both in the superficial femoral artery and below the knee arteries.
Successful angioplasty with stenting of the superficial femoral artery, and balloon angioplasty of the anterior tibial and dorsalis
pedis artery, was achieved.
endovascular surgery, it has slowly superseded open bypass
surgery, and has been shown to be an effective and durable
form of treatment. Even in patients with extensive multi-
segmental occlusive disease, both pedal bypass and endo-
vascular revascularization have been shown to be equally
effective.12e17
In patients with extended tissue loss, free flap recon-
struction is often required as part of the treatment plan for
limb salvage. Combined vascular reconstruction and free
flap surgery has become a viable option for limb salvage in
patients with critical limb ischemia and large soft-tissue
defects. Since Briggs’ initial report of combining bypass
surgery with free flap reconstruction, the possibility of
salvaging limbs that were deemed to require major ampu-
tations was now feasible.1e6 Numerous authors have made
the observation that the free flap can serve as a sole
outflow for the bypassed graft increasing its success
rate.18e20 Lorensetti found that the transferred muscle flap
acts as a low-resistance outflow bed, increasing the
bypassed graft outflow by as much as 50%.21 Mimoun et al.
described neovascularization of the surrounding ischemic
tissue from the free muscle flap occurring 3 weeks after
free flap surgery and so they named this the “nutrient
flap”.22 Randon described that these neovascularizations,
new collaterals, allowed the flap to keep on surviving even
1411
when the bypassed vessel has occluded.4 The above ob-
servations form the basis for the current consensus in the
treatment of ischemic lower limbs with extended soft-
tissue loss.
Over the last decade, with advances in imaging tech-
nique, angioplasty equipment, and endovascular exper-
tise, endovascular procedures have gained increasing
popularity as the initial form of treatment of revascular-
ization. Many centers are now suggesting “endovascular
treatment first” in the management of critical limb
ischemia. The introduction of stents coated with anti-
restenotic medication has revolutionized endovascular
therapies. Three multicenter randomized trials (the
YUKON-BTK, the DESTINY, and the ACHILLES trials) now
provide evidence with regard to the use of drug-eluting
stents in the infrapopliteal area.23e25 These trials show
that the use of drug-eluting stents prolongs vessel patency
with a trend towards improved wound healing. A recent
multicenter randomized trial, BASIL (Bypass versus An-
gioplasty in Severe Ischemia of the Legs), suggests that
endovascular angioplasty first is equivalent to bypass first
for patients with critical limb ischemia. The clinical ad-
vantages of endovascular treatment were well described
in this study. General anesthesias were not required in
endovascular treatment and it is associated with no or
1412
Figure 4 aecFourth and fifth toe open amputation as well as debridement of the lateral foot was performed at the same time as
the endovascular intervention. A free vastus lateralis muscle flap with skin graft was performed for reconstruction. There was good
survival of the flap and skin graft at 1-year follow-up.
fewer surgical wounds. It showed that even after 6 months
there were no significant differences in the amputation-
free survival rate, but the first year hospital costs were
higher in the surgery-first group. Surgery was also associ-
ated with a higher morbidity rate, with more time spent in
a high-care or intensive care units, as well as increased
length of hospital stay.26 Overall, there are increasing
amounts of data supporting the use and effectiveness of
endovascular therapy in the revascularization of critical
limb ischemia. It has a favorable risk-to-benefit ratio,
which allows this form of treatment to be available to a
broader spectrum of patients.
Some initial investigators have suggested that in diabetic
patients and renal disease patients with distal arterial oc-
clusions as well as extended soft-tissue loss, limb salvage is
not suitable and that primary amputation is the preferred
treatment of choice. However, there is now evidence
available to show that limb salvage with a good success rate
is possible in these patients.27 Moran et al. found that renal
disease should not be considered a contraindication to free
tissue transfer.28 We found in an earlier study that limb
salvage in diabetic patients and patients with end-stage
renal disease resulted in 80% limb salvage in 5 years.29 In
the current study, all of the patients had a history of dia-
betes mellitus and six patients with end-stage renal failure
on hemodialysis. In all of these cases, their limbs were
successfully salvaged.
Our current treatment algorithm for patients with lower
limb ischemia together with a soft-tissue defect requires an
initial assessment of the peripheral vascular status by
means of clinical palpation of the peripheral pulses,
C.-C. Huang et al.
followed by recording of ABI and PVR. Occasional conven-
tional angiogram or computed tomographic angiogram is
required. We now perform endovascular revascularization
first with debridement of the wound immediately after the
endovascular procedure during the same anesthetic
episode, sparing the patient a further need for anesthesia.
Subsequent free flap reconstruction, if required, takes
place a week later.
In our hospital, since the implementation of endovas-
cular procedure, it has slowly taken over as the treatment
of choice for lower limb revascularization, with bypass
surgery being performed only when endovascular treatment
is not possible or has failed. Although endovascular pro-
cedures are effective in revascularization, patients with
extensive tissue loss will at times require a free tissue
transfer. In some of these patients if reconstruction is not
possible even with adequate revascularization, major
amputation will still be required. In our patients, due to
cultural beliefs (in Taiwan), many of our elderly patients
refuse to undergo major amputations of their limbs. They
would rather die than have their legs amputated; this has
happened on a number of occasions. They strongly believe
that what was given to them by their parents at birth, they
need to take it with them to meet their ancestors. This
belief makes it extremely difficult to convince them that,
at times, a simple transmetatarsal amputation or partial
foot amputation covered by a fillet flap will suffice. They
usually will not consent to further toe amputation, if the
circulation in the adjacent toe is still patent and it is not
actively infected. In many of our patients, regaining
ambulation might not be the end point of treatment but
Endovascular revascularization for lower limb salvage
preservation of limb was the ultimate objective. This cau-
ses us to try and over salvage at times; in some of these
patients, a primary major amputation might have been
more beneficial.
In this study, we waited for a 1-week interval between
endovascular intervention and free flap reconstruction, to
ensure that the angioplastied vessels remain patent, and no
acute thrombosis or intimal dissection had occurred. Once
no complications are seen, free flap reconstruction can
than take place. The recipient vessel, the dorsalis pedis,
and the anterior tibial artery or the posterior tibial artery
are the most commonly used. In one case, the angioplastied
bypassed graft was used. The concomitant veins were the
most commonly chosen recipient vein. At times, the greater
saphenous vein can be used as the recipient vein. This will
not be possible if in-situ greater saphenous vein bypass had
been performed. If the recipient artery is atherosclerotic,
we try to find a portion of the artery that is the least
atherosclerotic and perform anastomosis to the least
diseased area. If this is not possible, then endarterectomy
is performed prior to vascular anastomosis. Free flap is only
abandoned if the vessel is so heavily calcified that endar-
terectomy is not possible and when the surgical needle
could not penetrate the calcified vessel wall making anas-
tomosis impossible. We found that we managed to achieve
a 100% flap success rate with a 1-year limb salvage rate of
96% and 92% at 2-year follow-up. One patient died 5 days
after free flap reconstruction due to acute myocardial
infarction. No further deaths or major medical conditions
were encountered in this group of patients. This is
encouraging, as this is comparable to studies using com-
bined bypass surgery with free flap reconstruction. We
initially expected a higher flap failure rate, or a higher flap
salvage rate, as we were performing vascular anastomosis
to the native pedal vessels. These tend to be more heavily
diseased with atherosclerotic plagues and calcifications
than the bypassed vessel, making microvascular anasto-
mosis more difficult. However, this was not the case, even
though it was technically more difficult. The overall flap
survival rate was good, with partial flap failure seen in only
three cases (12%). A high wound infection and partial loss of
skin graft were seen in this series. These patients being
placed on antiplatelet therapy after the endovascular
procedure, leading to persistent oozing and a higher rate of
hematoma formation, could explain this. However, there is
a shortcoming to our retrospective study, as we could not
look at the patients where free flap transfer was abandoned
when no suitable recipient vessels could be used. In some
cases, the recipient vessels were so calcified that micro-
surgery was not possible; in these cases, free flap surgery is
often abandoned, opting for conservative treatment with
dressing changes. This might explain the low flap failure
rate seen in this study. But in these same cases, bypass
surgery might also have been abandoned due to the poor
condition of the pedal vessels. However, with endovascular
intervention, we now give these patients a fighting chance
as with improved revascularization, even though free tissue
transfer is not possible, but with frequent dressing changes
or with the adjuvant usage of vacuum-assisted closure
systems as well as hyperbaric oxygen therapy, some of the
limbs are saved, even though wound healing takes place
over a longer period of time.
1413
In conclusion
For reconstructive and vascular surgeons involved in lower
limb salvage, we are exposed more and more to endovas-
cular revascularization. We found that the success rate of
lower limb salvage using a combination of endovascular
revascularization and free tissue reconstruction is compa-
rable to using a combination of bypass surgery and free
tissue transfer. It is suitable for diabetic patients and even
for diabetic patients with renal disease. It provides us with
yet another treatment option in the management of
ischemic lower limbs with extended tissue loss.
Acknowledgments
Competing Interest: None of the authors has a financial
interest in any of the products, devices, or drugs mentioned
in this manuscript.
Funding: None declared.
Ethical Approval: IRB approved.
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