Effendi Maleeh, Ha Austin Y, Felder John M
Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio.
Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, Mo.
Plast Reconstr Surg Glob Open. 2020 Feb 20;8(2):e2612. doi: 10.1097/GOX.0000000000002612. eCollection 2020 Feb.
Lower extremity salvage using microvascular flaps can be considered in high-functioning patients, but indications for salvage are often restricted by distal microvascular disease that may threaten the foot as a whole. Selective arterialization of specific pedal venosomes is a novel potential solution to this problem.
A 48-year-old man with a chronic left plantar forefoot wound, osteomyelitis of the second and third metatarsal heads, and critical limb ischemia was evaluated for foot salvage. Despite a patent popliteal to posterior tibial bypass graft, residual ischemia was present in the first and second toes due to severe microvascular disease. This wound was reconstructed with a free partial medial rectus abdominis flow-through flap based on the medial branch of the deep inferior epigastric artery. The lateral branch was used as a flow-through vessel to arterialize the dorsal veins of the first webspace.
Arterialization of the first webspace veins resulted in an immediate intraoperative improvement of the color of the first and second toes, along with creation of an arterial Doppler signal. The flap effectively covered the wound. The patient went on to heal completely and return to unrestricted ambulation. Transcutaneous oxygen measurement values of the dorsal foot improved from 35.8 mm Hg preoperatively to 48.3 mm Hg postoperatively.
In patients with focal areas of critical ischemia, selective arterialization of the venous system may be an effective method of preventing tissue loss and improving wound healing. A flow-through flap can be used to accomplish this in tandem with wound reconstruction.
对于功能良好的患者，可以考虑使用微血管皮瓣进行下肢挽救，但挽救的指征常常受到远端微血管疾病的限制，这种疾病可能会威胁整个足部。特定足背静脉体的选择性动脉化是解决这一问题的一种新的潜在方法。
对一名48岁男性进行评估，该患者有慢性左足底前足伤口、第二和第三跖骨头骨髓炎以及严重肢体缺血，考虑进行足部挽救。尽管腘动脉至胫后动脉旁路移植血管通畅，但由于严重的微血管疾病，第一和第二趾仍存在残余缺血。采用以腹壁下动脉内侧支为蒂的游离部分腹直肌穿支皮瓣修复该伤口。外侧支用作穿支血管，使第一趾蹼间隙的背侧静脉动脉化。
第一趾蹼间隙静脉的动脉化使术中第一和第二趾的颜色立即改善，并产生了动脉多普勒信号。皮瓣有效地覆盖了伤口。患者最终完全愈合，恢复了不受限制的行走。足背经皮氧分压测量值从术前的35.8 mmHg提高到术后的48.3 mmHg。
在严重缺血的局部区域患者中，静脉系统的选择性动脉化可能是预防组织丢失和促进伤口愈合的有效方法。穿支皮瓣可与伤口重建一起用于实现这一目的。
