Salvage of a Free Flap Using Postoperative Percutaneous Angioplasty in Patients with Diabetic Foot Ulcers

Copyright 2014 The Korean Society of Plastic and Reconstructive Surgeons This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. artery can occur, and unless resolved before anastomosis, it may lead to flap failures [3]. Herein, we report 2 cases of prolonged recipient arterial compromises that occurred abruptly after donor flap harvest. We solved these situations by performing PTA postoperatively, and this report describes our experience. Patient 1 was a 74-year-old woman with a diabetic ulcer on her third and fourth toes on the left. Serial debridement resulted in a 4 × 5-cm open wound with the exposure of the third and fourth metatarsal bones (Fig. 1A). Preoperative angiography showed multifocal stenoses throughout the lower extremity vasculature, including the left dorsalis pedis artery (DPA) and metatarsal arteries. Successful revascularization with PTA was performed by an interventional radiologist (Fig. 2A). Three weeks later, anterolateral thigh free flap was used to cover the skin defect of the left foot. Pulsatile flow in the DPA was assessed using intraoperative Doppler and clinical inspections. The calcified portion of the DPA was resected, and the flow-through flap was harvested from the patient’s thigh. After removal of the microvascular clamp before anastomosis, the DPA became thrombotic; therefore, we performed thrombectomy using the Fogarty catheter. The thrombosis resolved, but spasms were observed even after irrigation with heparin and papaverine. Once flow-through anastomosis was completed, the flap showed several signs of compromise and poor Doppler signals. As we could not find another recipient vessel, we planned to revascularize the recipient artery postoperatively, and then complete the operation. After 13 hours, we revascularized the completely occluded DPA (Fig. 2B) using a 1.5-mm balloon catheter and checked active flap blood flow Although microsurgical reconstruction of the diabetic foot has shown high success rates in recent studies, it remains challenging in patients with peripheral arterial disease (PAD) [1]. Free flap surgery should be performed in PAD patients after establishing blood flow preoperatively by using percutaneous transluminal angioplasty (PTA) or bypass surgery [1,2]. However, even after successful revascularization, intraoperative spasm or thrombosis of the recipient