Malikov Sergueï, Magnan Pierre-Edouard, Champsaur Pierre, Casanova Dominique, Branchereau Alain
CHU La Timone, Service de Chirurgie Vasculaire, Marseille, France.
J Vasc Surg. 2008 Jul;48(1):159-66. doi: 10.1016/j.jvs.2008.02.023. Epub 2008 May 2.
Major tissue loss caused by the critical limb ischemia requires improvement of distal perfusion and cover of large tissue defects. We propose a new method, the y-shaped subscapular artery flow-through (Y-SCAFT) muscle flap using the subscapular artery that yields an arterial graft and a free muscle flap sustained by a collateral branch of this artery. This prospective study evaluated the feasibility of this technique and analyzed wound healing, graft patency, and limb salvage.
Between 2002 and 2007, 20 patients, mean age 64 years (range, 55-79 years), were treated with this technique. All presented with critical ischemia and major tissue loss, with exposure of the tendons, bones, or joint, and were candidates for major amputation. Revascularization and cover of tissue loss with the same Y-SCAFT anatomic unit was used for all patients. The distal anastomosis was performed between the distal branch of the Y-SCAFT and the pedal artery in 9, posterior tibial artery in 4, peroneal artery in 1, lateral tarsal artery in 3, and the plantar artery in 3. In four patients, the distal part of the arterial graft, including the anastomosis, was covered with the muscle flap because the tissue loss was nearby. The proximal anastomosis was performed between a leg artery and the arterial graft in 10 patients. A venous graft was necessary in 10 patients to extend the bypass proximally.
One patient died during the postoperative period. Duplex control evidenced patency all the Y-SCAFT muscle flaps. Healing was achieved in all patients. Mean follow-up was 31 months (range, 6-58 months). No patients died during follow-up. One patient presented occlusion of the Y-SCAFT muscle flap and underwent amputated. One patient had major amputation despite a patent graft. At 2 years, leg salvage was 85%, patency was 94%, and survival was 94%. At the end of the follow-up, 17 patients (1 death, 2 amputations) had a patent graft, a viable muscle flap, wound healing, and a functional leg.
We showed the clinical feasibility of the technique of Y-SCAFT muscle flap, which allows for revascularization and cover of major tissue loss with one anatomic unit. This method is particularly useful in selected cases with poor run-off and large ischemic lesions.
严重肢体缺血导致的大面积组织缺损需要改善远端灌注并覆盖大面积组织缺损。我们提出一种新方法，即使用肩胛下动脉的Y形肩胛下动脉穿支（Y-SCAFT）肌皮瓣，该方法可产生一个动脉移植物和一个由该动脉的侧支维持的游离肌皮瓣。这项前瞻性研究评估了该技术的可行性，并分析了伤口愈合、移植物通畅情况和肢体挽救情况。
2002年至2007年间，20例平均年龄64岁（范围55 - 79岁）的患者接受了该技术治疗。所有患者均表现为严重缺血和大面积组织缺损，伴有肌腱、骨骼或关节外露，均为大截肢的候选者。所有患者均使用相同的Y-SCAFT解剖单元进行血运重建和组织缺损覆盖。Y-SCAFT的远端分支与足背动脉吻合9例，与胫后动脉吻合4例，与腓动脉吻合1例，与跗外侧动脉吻合3例，与足底动脉吻合3例。4例患者因组织缺损靠近动脉移植物远端部分（包括吻合口），故用肌皮瓣覆盖。10例患者在腿部动脉与动脉移植物之间进行近端吻合。10例患者需要静脉移植物以向近端延长旁路。
1例患者在术后期间死亡。双功超声检查证实所有Y-SCAFT肌皮瓣均通畅。所有患者均实现愈合。平均随访31个月（范围6 - 58个月）。随访期间无患者死亡。1例患者出现Y-SCAFT肌皮瓣闭塞并接受截肢。1例患者尽管移植物通畅但仍进行了大截肢。2年时，肢体挽救率为85%，通畅率为94%，生存率为94%。随访结束时，17例患者（1例死亡，2例截肢）移植物通畅、肌皮瓣存活、伤口愈合且腿部功能良好。
我们证明了Y-SCAFT肌皮瓣技术的临床可行性，该技术可通过一个解剖单元实现血运重建和覆盖大面积组织缺损。该方法在特定的流出道差和大面积缺血性病变的病例中特别有用。
