Combined Distal Venous Arterialization and Free Flap for Patients with Extensive Tissue Loss
Article Outline
- Abstract
- Introduction
- Patients and Methods
- Results
- Discussion
- Conclusions
- Acknowledgment
- References
- Copyright
Background
We evaluated the mid-term outcome of distal venous arterialization (DVA) and the role of a combined free flap as a bridgehead for blood supply.
Methods
In the past 5 years, nine patients with extensive tissue loss and lacking graftable distal arteries underwent DVA. These consisted of four primary DVAs, three combined DVA and free flap procedures, and two adjuvant DVAs for hemodynamically failed distal bypasses. After nine primary DVAs, three redo DVAs were performed for early failure. Etiologies were four Buerger disease and five arteriosclerosis obliterans, including three dialysis patients.
Results
Among the nine DVA cases, there were five primary failures: two underwent amputation, two had successful redo DVA, and the remaining one did not require redo DVA. Primary patency, secondary patency, and limb salvage rates were 44.4%, 55.6%, and 77.8%, respectively. The postoperative period was 1–36 months (median 12). Angiography demonstrated DVA was effective in the early period, and development of collaterals or a capillary network from the free flap replaced the DVA function in the intermediate period.
Conclusion
DVA can be effective as a procedure for limb salvage in patients without graftable distal arteries, and a combined free flap is effective and functions as a bridgehead for blood supply to the ischemic zone.
Introduction
In limb salvage, there have been three steps in the development of surgical management. The first step was paramalleolar arterial bypass, which is the choice of operation for foot salvage in patients with Buerger disease (thromboangiitis obliterans, TAO) as well as diabetic ischemic gangrene; and this aggressive bypass strategy has been justified by a significant decrease in major amputation rates.1, 2 The second evolution was application of free tissue transfer combined with distal arterial bypass,3 which has also contributed to limb salvage in patients with extensive tissue loss. The latest step is distal venous arterialization (DVA), in which the procedure is truly indicated, although candidates are limited. When angiography demonstrates the absence of graftable distal arteries, DVA may be possible as a last resort for limb salvage. Taylor et al.4 improved the techniques and reported in 1999 an immediate high success rate of limb salvage; however, according to a recent meta-analysis of DVA reports,4, 6, 7, 8 secondary patency and foot preservation rates at 1 year were only 46% and 71%, respectively, indicating that the intermediate-term outcome is not acceptable.
Against this evolutionary background of limb salvage treatment, if a patient with extensive tissue loss has no graftable distal arteries, the patient is a suitable candidate for combined DVA and free flap; however, because of the limited number of DVA candidates, neither the combined procedure nor the functional role of the free flap has been reported. In the present study, we report the outcome of DVA with or without a free flap for patients with extensive tissue loss without graftable distal arteries and discuss the mid-term biological fate of DVA and the role of the free flap as a nutrient for limb salvage.
Patients and Methods
Patients
Between January 2003 and July 2007, we employed DVA for limb salvage as a final resort. DVA candidates were definitively selected, and there were nine patients who required DVA because of no graftable distal arteries (Fig. 1A, Table I). The nine included four TAO and five arteriosclerosis obliterans (ASO), including three on dialysis, and they complained of intractable rest pain, which was mainly controlled by continuous epidural analgesics. They had progressive extensive tissue loss with exposed bone, and six had virulent organism infection such as methicillin-resistant Staphylococcus aureus (MRSA), Escherichia coli, and/or Pseudomonas aeruginosa. The indications of DVA were progressive gangrene due to disease progression in all TAO patients (Fig. 2A, B) as well as in three ASO patients with dialysis and extensive thrombosis of paramalleolar and foot arteries after percutaneous angioplasty (Fig. 1A) or blue toe syndrome (Fig. 3A) associated with ASO. The indications were evaluated by preoperative angiography, but four ASO patients required intraoperative angiography from the below-knee popliteal artery for final decision making. All five ASO patients had no history of arterial bypasses, whereas all TAO patients had a long clinical history, with single or multiple redo bypasses or lumbar sympathectomy.
Fig. 1
A 74-year-old female with ASO, candidate for DVA. A Intraoperative angiography from below the knee popliteal artery demonstrated entire paramalleolar and foot artery occlusion. B Venography after complete valve destruction, visualizing the plantar arch and metatarsal veins (arrows). C Seven days after DVA, showing a characteristic darkish pink skin. D Four months after pedal plasty.
Table I. Patient characteristics
| Patients | DVA | |||
|---|---|---|---|---|
| No., age, sex, disease | Indications | Op. date | ABI | Tissue loss |
| Combined DVA and free flap | ||||
 1, 64, M, TAO | Disease progression | 1/03 | 0.1 Lateral half of foot | |
| 2, 58, M, TAO | Disease progression | 9/04 | 0 | Distal to Lisfranc joint |
| 3, 60, M, ASO/DM | Microatheroembolism | 7/06 | 0.3 | 1st-2nd metatarsal bone |
| Primary solitary DVA | ||||
| 4, 74, F, ASO | Thrombosis | 6/06 | 0.4 | Distal to Chopart joint |
| 5, 51, M, TAO | Disease progression | 3/06 | 0 | Forefoot to Chopart joint |
| 6, 53, M, TAO | Disease progression | 5/07 | 0.4 | 2nd toe |
| 7, 58, F, ASO/DM/dialysis | Disease progression | 4/07 | inc. | Entire sole/thrombosis |
| Adjuvant DVA for hemodynamically failing distal arterial bypass | ||||
| 8, 48, M, ASO/DM/dialysis | Disease progression | 8/06 | inc. | Lateral half of heel |
| 9, 72, M, ASO/DM/dialysis | Disease progression | 7/07 | inc. | 2-4 toes, metatarsal area |
Fig. 2
A 56-year-old TAO patient who underwent simultaneous operation with combined DVA and free flap for progressive gangrene: A 1 month before DVA; B preoperative finding of extensive tissue loss; C 6 months after free flap.
Fig. 3
A 60-year-old diabetic ASO patient who underwent a two-stage operation of combined DVA and free flap. A Before DVA, B free flap performed 3 months after DVA, C after 5 months.
DVA Procedures
Among the nine patients, there were four primary solitary DVAs, three combined DVA and free flap procedures, and two adjuvant DVAs performed in dialysis patients at the time of an attempted bypass because of low graft flow or hemodynamically failed conventional arterial bypass (Table II). After these nine primary DVAs, in one simultaneous DVA and free flap case, an additional DVA was performed to create an arterial access for the free flap, and three redo DVAs were performed for DVA failure.
Table II. Results of DVA with or without free flap
| DVA | Free flap | ||
|---|---|---|---|
| No., procedure | Graft type, function (follow-up) | Graft type, function (follow-up) | Outcome/status |
| Combined DVA and free flap | |||
| 1, Graft-MPV | RVG (arm vein) | RcAb | |
| F (1 month) | P/Fu (26 months) | Healed/died 26 months | |
| 2, FA-MPV | RVG (spliced vein) | RcAb | |
| P/Fu (36 months) | P/Fu (34 months) | Healed/ambulation | |
| 3, BKP A-MPV | ISVG | ||
| P/Fu (14 mo) | — | ||
| Adj-DVA, graft-DPV | RVG | Scpl | |
| P/Fu (10 months) | P/Fu (10 months) | Healed/ambulation | |
| Primary solitary DVA | |||
| 4, BKPA-LPV | RVG | ||
| P/meager (12 mo) | — | Healed/died | |
| 5, FA-ATV | RVG (spliced vein graft) | ||
| F (3 days) | — | ||
| Redo FA-CPV | ePTFE/6mm | ||
| F (1 day) | — | Amputation | |
| 6, BKPA-DPV | ISVG | ||
| F (1 day) | — | ||
| Graft revision | RVG (spliced vein graft) | ||
| P/Fu (4 months) | — | Healed/rehabilitation | |
| 7, BKPA-DA | ISVG-RVG | ||
| F (1 day) | — | Amputation | |
| Adj. DVA for hemodynamically failing distal arterial bypass | |||
| 8, Adj. graft-CPV | Direct anastomosis | ||
| F (5 months) | — | ||
| Redo adj. graft-DPV | RVG arm vein | ||
| F (3 months) | — | Healed/rehabilitation | |
| 9, Adj. graft-LPV | ISVG-direct anastomosis | ||
| P/Fu/ (2 months) | — | Healing/rehabilitation/died | |
Operative Technique
The target vein was selected based on the location of gangrene with infection and the anatomical advantage of a free flap. In six of the nine, we primarily used plantar veins; in another, we selected the dorsal pedal vein because of the advantage for a later free flap, but thrombotic occlusion occurred within 24hr, so the plantar vein was used in redo DVA. In the remaining two, neither vein was available, and the superficial dorsal arch vein or the anterior tibial vein was used.
After intravenous administration of heparin, the common plantar vein was ligated 2cm proximal to the bifurcation and longitudinally opened distal to the ligation. Proximally located valves were bluntly destroyed by means of a surgical probe (Fig. 4A), and then fine catheters, such as a trial production balloon catheter with an outer diameter of 0.75mm (Nipuro, Osaka, Japan), a 2F Fogarty balloon catheter (Edwards Lifesciences, Irvine, CA), and/or a Parsonnet probe (C.R. Bard, Murray Hill, NJ) with an outer diameter of 1mm, were passed up and placed immediately proximal to the distal bifurcation of the medial plantar vein or to the deep plantar arch vein of the lateral plantar vein for distal valve destruction (Fig. 4B). The distal fine valves were easily destroyed by gently passing a catheter through without the firm push required for proximal valves, and weak resistance could be felt through the catheter at the site of destruction. In three cases, we used a microangiofiberscope with an outer diameter of 0.75mm (Microendoscope®; Fibertech, Rochester, NY) to confirm the valve destruction. After completion of the valve destruction, retrograde venography was performed from the venotomy to confirm visualization of the plantar metatarsal veins or the dorsal metatarsal veins connecting to the plantar or the dorsal pedal veins (Fig. 1B).
Fig. 4
Technique of valve destruction. A The common plantar vein is dissected, ligated 2
cm proximal to the bifurcation, and longitudinally opened distal to the ligation. Proximal valves of the medial and lateral plantar veins are destroyed by a surgical probe. B Fine catheters are inserted distally to the plantar vein for destruction of fine valves. C Visualization of plantar metatarsal veins is confirmed by venography, and then anastomosis between the vein graft and the common plantar vein is performed.
Vein grafts were used exclusively: Four in situ saphenous vein grafts and eight reversed vein grafts, including three spliced vein grafts, were employed. In one TAO patient, an expanded polytetrafluoroethylene graft was used for redo DVA. For proximal anastomosis of DVA grafts, we selected the common femoral artery, superficial femoral artery, below-knee popliteal artery, or hemodynamically failed femoroanterior tibial artery or plantar artery bypass graft. Anastomotic techniques were the same as for a conventional arterial bypass: The length of the anastomosis was 8-10mm, and all anastomoses were performed with 8-0 polypropylene continuous sutures using a ×3 magnification loupe.
There are many connections between superficial veins and plantar veins which decrease the pressure of the DVA system, whereas complete ligation may cause graft failure due to extremely low graft flow. Several branches originating from the proximal segment of the plantar veins become arteriovenous fistulas (AVFs), but small branches originating from the distal segment of plantar veins contribute to the maintenance of adequate graft flow. In order to obtain the optimal flow volume (20-40mL/min), the proximally located branches were ligated individually under monitored graft flow (ultrasound transit time flow meter, Vutterfly®; Medi-Stim, Oslo, Norway). When the graft flow decreased below 20mL/min after ligation, the last branch was left unligated (Fig. 4C), and the graft flow after completion of ligation was ultimately controlled at 15-50mL/min (median 40).
A free flap was indicated for extensive tissue loss with exposed bone. Of three patients receiving combined DVA and free flap, one TAO patient underwent a simultaneous operation and two others received vacuum-assisted closure management for infection control after DVA and then underwent free flap as a second-stage operation, with intervals of 3 weeks to 4 months. The type of free flap was selected based on the size of tissue loss, thickness of the flap, whether or not the area to be repaired was weight bearing, and/or locational advantage in harvesting; and the rectus abdominis flap, the scapular fasciocutaneous flap, or latissimus dorsi muscle flap was used. A free flap was harvested immediately before transplantation, and the free flap artery was anastomosed to the distal site of the DVA graft in an end-to-side manner. The vein of the free flap was usually anastomosed to the proximal segment of the vein used for DVA, such as the terminal posterior tibial vein or the dorsal pedal vein.
Postoperative Management
Neither the skin perfusion pressure nor the toe pressure measurement was applicable because of extensive gangrene. Therefore, effective retrograde perfusion of the DVA was evaluated by the change of skin color to a characteristic darkish pink. Newly opened AVFs were the most important factor for reaggravation of ischemia. When significant bruits developed and manual AVF occlusion improved the skin color to pink, ligation of the AVF was performed. Postoperative anticoagulants were not given, but statins or low-dose aspirin, or both, were administered.
Serial angiographies were performed to evaluate changes of blood supply patterns and the DVA outcome. In seven cases with successful limb salvage (two DVAs alone, three DVAs with free flap, and two adjunctive DVAs for hemodynamically failed distal arterial bypass), three cases with primary patent DVA, one with failed DVA and functioning free flap, and two redo DVAs were available for evaluation. The remaining one case was excluded because of the short observation period after surgery. During observation periods ranging 4-36 months (median 12), serial angiographies were performed two to six times per case (total 19 times) at 1-30 months after DVA.
Results
Patients Who Underwent Primary Solitary or Adjuvant DVA
Of four patients who underwent primary solitary DVA, two had early DVA graft failure due to graft shortness or acute irreversible ischemic change, resulting in amputation. In the remaining two (who had successful DVA or redo DVA performed for early thrombosis), we succeeded in limb salvage. The foot in which DVA was performed regained a characteristically pink skin (Fig. 1C). Ischemia reccurred in one patient 2 weeks after DVA because of a delayed open AVF; however, the skin color immediately returned to pink after ligation for the AVF. The deep wound was gradually covered by granulation tissue, and pedal plasty with surviving excess tissue was performed after 4 months (Fig. 1D). In the meantime, sufficient collateral arteries developed while the DVA lapsed into dysfunction, and the vein graft hemodynamically failed without any symptoms after 6 months.
Of two adjuvant DVAs for an arterial bypass, one failed after 5 months and the subsequent redo DVA also failed after 3 months; however, a wound with extensive tissue loss completely healed 7 months after DVA, and we succeeded in limb salvage. In the other patient, the DVA continued functioning, and the distal half of the foot with extensive tissue loss was exclusively nourished by the DVA; however, he died of myocardial infarction 2 months after surgery.
Patients Who Underwent Combined DVA and Free Flap
Of the three patients who underwent combined DVA and free flap (Fig. 2, Fig. 3), two with TAO demonstrated characteristic darkish pink skin, and rest pain was relieved after 2-4 weeks. One patient with a spliced vein graft had graft stenosis 18 months after surgery. Because no veins were available, a 10-cm-long right gastroepiploic artery was used for replacement of the graft segment. The remaining patient, who had ASO, had operative wound dehiscence due to MRSA infection after DVA; however, angiography after 8 weeks demonstrated a distal venous system with retrograde perfusion. After control of the infection, adjunctive DVA bypass for free flap was placed from the initial DVA graft to the dorsal pedal vein, and a free flap was performed 3 months after the initial DVA (Fig. 3B, C).
Changes in Blood Supply Patterns to the Ischemic Zone
In the seven patients with definitely successful procedures and limb salvage, the DVA was obviously functioning and effective in the early postoperative period; however, serial angiographies in the intermediate period in five patients demonstrated three different changes of blood supply modality, which are summarized as follows: (1) DVA and free flap both functioning well without development of collaterals, in one patient (Fig. 5A); (2) failed DVA without development of collaterals and functioning free flap with supplementary vascular ingrowth to surrounding ischemic zone, in two patients (Fig. 5B); (3) failing or failed DVA with development of vigorous collaterals, in two patients (Fig. 5C). In (1), there was narrowing of the vein graft and DVA venous system, probably due to arterialization, but both the DVA and the free flap nourished their respective areas in the foot. In (2), the DVA venous system atrophied and failed but the free flap connected to the DVA graft continued to function and formed a blood supply network to the ischemic zone, with an increase of caliber in the free flap artery. In (3), complete recovery from critical limb ischemia was attained, while the DVA became meager, changed to a simple AVF, and ultimately failed.
Fig. 5
Blood supply modalities in the foot in the intermediate period after DVA with or without free flap. A Well-functioning DVA (arrows G1, G2: vein grafts of primary and secondary DVA) and free flap (arrow F) seen in the case of Figure 3 (10 months after DVA). B Failed DVA but patent vein graft (arrow G) with functioning free flap (arrow F) with supplementary vascular ingrowth and blood supply to the surrounding ischemic zone seen in the case of Figure 2 (30 months after DVA). C Failing DVA graft (arrow G) and collateral development from native proximal arteries seen in the case of Figure 1 (5 months after DVA).
DVA Patency Rate and Limb Salvage
In nine patients, the lengths of hospital stay were 1 week to 3 months (median 3 weeks), and they underwent one to three procedures (median 2). Of nine various types of DVAs, there were five primary failures, of which two resulted in amputation; two underwent successful revision or redo surgery; and the remaining patient, who had a free flap, did not require redo DVA because of improvement of ischemia by microangiogenesis from the free flap. Seven patients with successful limb salvage started rehabilitation 3-20 weeks after DVA or pedal plasty. Of seven, five had passed 12 months after DVA and regained satisfactory gait function without any prosthesis for short walks after 5-8 months (median 3). The primary and secondary patency rates of DVA were 44.4% (4/9) and 55.6% (5/9), and limb salvage was attained in seven of nine patients (77.8%) during the follow-up period of 2-36 months (median 12).
Discussion
Postoperative functional outcomes after major amputation depend on the preoperative status and level of amputation, and therefore a wide range (16-96%) in ambulatory ability after major amputation has been reported.9 When younger, muscular patients with or without peripheral arterial disease have undergone major amputation, the functional outcomes were similar to what might be expected after successful revascularization. Conversely, the functional outcomes and mortality after major amputation are poor in patients with limited preoperative ambulatory ability, older age, or end-stage vascular disease.10 In critical limb ischemia, 30% of patients who underwent amputation died within 2 years and another 30% required reamputation or contralateral limb amputation,11 while several studies have proved that successful revascularization improves quality of life.12, 13 Against this background, we set out to clarify the efficacy of DVA and combined free flap grafting as a final resort for limb salvage and selected the nine patients as definitive DVA candidates, which represents 3.9% of patients undergoing bypasses for critical limb ischemia in the same period of time. All of the patients positively accepted a long-term treatment plan with multiple procedures which might enable limb salvage.
To evaluate efficacy in limb salvage, it is necessary to differentiate the effects of intervention from those developing from natural improvement. Ischemia may induce microangiogenesis, and 25% of critical limb ischemia naturally improves;11 however, if gangrene is progressive, it is necessary to provide a definitive treatment for stopping the progression. In the present candidates, natural improvement was not expected because gangrene was clearly progressive, and the progression stopped after DVA in either DVA alone or DVA with free flap. Taylor et al.4 speculated that neovascularization takes place in response to AVF with the development of new arteries and, due to development of collaterals, limb salvage can be attained even after graft failure, while Root and Cruz14 reported that peripheral AVFs may be a potent stimulus to the growth of arterial and venous collateralization. Nevertheless, if DVA is actually effective, retrograde blood flow must reach a significantly distal level of the microcirculation, and it appears that limb salvage is accomplished by different mechanisms in the acute and the intermediate phases.
In the acute phase, nourishment by diffusion is speculated to be the main mechanism: As many previous reports regarding diffusion have suggested,15 arterial walls thinner than 0.5mm must be nourished entirely by diffusion from the lumen or adventitial vessels, and diffusion efficiency is enhanced by arterialization of the venous system with thinner walls. In DVA, therefore, an ischemic area beyond 500μm must be nourished by diffusion alone, even though oxygenized blood does not reach capillaries.
In the intermediate phase, the patency rates of DVA bypasses are poor, and the mechanism of DVA dysfunction remains unclear. In order to clarify the reasons for DVA failure and the mechanism of clinical improvements in each successful case, we performed repeated angiography, which clearly demonstrated changes in the perfusion zone of the DVA and dominant perfusion vessels. We found three angiographic patterns and concluded that DVA may continue to work as long as significant collaterals do not develop, while the DVA venous system gradually diminishes and lapses into dysfunction in association with vascular ingrowth from the free flap or development of native collaterals. Furthermore, the mechanisms leading to limb salvage are considered to differ between cases of DVA alone and those of DVA with a free flap: In DVA alone, development of collaterals gradually progresses for several months and then antegrade flow becomes dominant, while retrograde flow via the DVA gradually decreases and ultimately changes to a simple AVF. On the other hand, in DVA with a free flap, a capillary network between microvessels of the free flap and ischemic tissue is established within about 3 weeks.16 Thereafter, antegrade flow from the free flap gradually becomes dominant in the same way as DVA alone.
In the DVA procedure, adequate valve destruction in the target vein and its distal venous system is important, and metallic olives,6 Parsonnet probe,4, 5 Fogarty catheter, and/or guidewires17 have been used. The proximally located valves can be surgically destroyed, but incompetence of microvalves is induced only by high venous wall tension generated by arterial pressurization. Major AVFs not only steal blood flow from the distal venous system but also reduce vessel wall tension, suppressing induction of distal valve incompetence. As seen in the present cases, delayed opening of a significant AVF markedly aggravated ischemia. Historically, Szilagyi et al.18 attempted DVA of the superficial femoral vein in nine cases, but there were no responders. Use of the superficial pedal venous arch of the distal saphenous vein17, 19, 20 or crural saphenous vein21 has been reported. Since small superficial veins from the toes feed into the dorsal venous arch which continues to the saphenous veins, DVA using the superficial veins is theoretically feasible; however, it is not easy to destroy valves of the dorsal venous arch, and the dorsal arch has many communicating branches, leading to major AVFs. Thus, we conclude that the venae comitans of the medial and/or lateral plantar arteries are the veins of choice for DVA as far as these areas are not encroached upon by gangrene or infection. Proximal branches of these veins close to the anastomosis lead to major AVFs and commonly require ligation, but ligation for distal branches requires graft flow monitoring. Because of a contradiction between sufficient graft flow produced by AVFs and high pressure in the DVA venous system, we routinely perform AVF ligations while measuring graft flow, controlled at about 40mL/min as the adequate value securing vein graft patency. Reducing the flow means not only reduction of excessive AVF flow but also maintenance of higher venous wall tension.
In order to assure limb salvage for a long-term period, a free flap as an alternative blood supply resource after DVA failure is necessary. Angiography in the present study demonstrated that a free flap combined with DVA not only covers a wound that has exposed bone but also plays the role of a bridgehead for blood supply to the ischemic zone. Mimoun et al.16 reported the concept of the nutrient flap and stressed the following three functions of the free flap: (1) it provides supplementary blood flow to ischemic zones, (2) it assists venous drainage in regions of venous insufficiency, and (3) it induces the formation of a capillary network. In critical limb ischemia, immediate effective arterial blood supply is necessary to prevent impending necrosis. Sunar et al.22 reported a free flap technique using an arteriovenous shunt for limb salvage; however, since a free flap requires 3 weeks to establish capillary ingrowth to surrounding tissue, it will not be effective at stopping the progression of gangrene; in addition, blood flow through an arteriovenous shunt may aggravate the ischemia. Therefore, even in combined free flap cases, DVA, not an arteriovenous shunt, is essential until the formation of vascular connections with surrounding tissue.
Conclusions
In patients without graftable distal arteries, DVA may be the procedure of choice for limb salvage; however, because long-term durability is limited, an adjunctive blood supply resource is necessary for the foreseeable dysfunction. When such patients have extensive tissue loss, a combined free flap with DVA not only is effective for wound coverage but also retains vein graft patency and continues function as a nutrient flap, resulting in a more satisfactory outcome in limb salvage when compared with DVA alone.
The authors are indebted to Professor J. Patrick Barron of the International Medical Communications Center of Tokyo Medical University for his review of this manuscript.
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PII: S0890-5096(09)00163-0
doi:10.1016/j.avsg.2009.07.001
© 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc All rights reserved.
