Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St, Boston, MA 02115, USA; Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.
Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St, Boston, MA 02115, USA; University of California, Riverside School of Medicine, Riverside, CA, USA.
J Plast Reconstr Aesthet Surg. 2021 May;74(5):1031-1040. doi: 10.1016/j.bjps.2020.10.045. Epub 2020 Nov 2.
Compromised lower limb perfusion due to vascular changes such as peripheral artery disease impedes wound healing and may lead to large-scale tissue defects and lower limb amputation. In such patients with defects and compromised or lacking recipient vessels, combined vascular reconstruction with free flap transfer is an option for lower extremity salvage.
By using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2018), we analyzed two patient cohorts undergoing (A) free flap lower limb reconstruction (LXTR) only and (B) combined (endo-)vascular reconstruction (vascLXTR). The preoperative variables assessed included demographic data and comorbidities, including smoking, diabetes mellitus, preoperative steroid use, and American Society of Anesthesiology (ASA) Physical Status Classification. Using a neighbor matching algorithm, we performed a 1:1 propensity score matching of 615 LXTR patients and 615 vascLXTR patients. Bivariate analysis for postoperative surgical and medical complications was performed for outcomes in the propensity-matched cohort.
We identified 5386 patients who underwent microsurgical free flap reconstruction of the lower extremity. A total of 632 patients underwent a combined (endo-)vascular intervention and lower extremity free flap reconstruction. Diabetes and smoking were more prevalent in this group, with 206 patients having diabetes (32.6%) and 311 being smokers (49.2%). More patients returned to the operating room in the cohort that underwent a combined vascular intervention (24.4% versus 9.9%; p<0.0001). The 30-day mortality for patients undergoing a combined vascular procedure was 3.5%, compared with 1.3% with free tissue transfer only (p<0.0001).
Despite the risks associated, the combined intervention decreases the very high mortality associated with limb amputation in severely sick patient populations. Careful preoperative assessment of modifiable risk factors may reduce complication rates while allowing limb salvage.
由于血管变化（如外周动脉疾病）导致下肢灌注受损，会妨碍伤口愈合，并可能导致大范围组织缺损和下肢截肢。对于存在缺陷且血管受损或缺乏受区血管的此类患者，联合血管重建和游离皮瓣转移是下肢挽救的一种选择。
我们使用美国外科医师学会国家外科质量改进计划（ACS-NSQIP）数据库（2005-2018 年），分析了仅行游离皮瓣下肢重建（LXTR）和（内）血管重建联合游离皮瓣转移（vascLXTR）的两组患者。评估的术前变量包括人口统计学数据和合并症，包括吸烟、糖尿病、术前皮质类固醇使用和美国麻醉医师协会（ASA）身体状况分级。采用邻居匹配算法，对 615 例 LXTR 患者和 615 例 vascLXTR 患者进行了 1:1 倾向评分匹配。对倾向评分匹配队列的术后手术和医疗并发症进行了二元分析。
我们确定了 5386 例行下肢显微游离皮瓣重建的患者。共有 632 例患者接受了联合（内）血管干预和下肢游离皮瓣重建。该组患者中糖尿病和吸烟更为常见，其中 206 例（32.6%）患有糖尿病，311 例（49.2%）为吸烟者。接受联合血管干预的患者中有更多患者返回手术室（24.4%比 9.9%；p<0.0001）。联合血管手术患者的 30 天死亡率为 3.5%，而仅行游离组织转移的患者为 1.3%（p<0.0001）。
尽管存在相关风险，但联合干预可降低严重疾病患者群体中与肢体截肢相关的极高死亡率。仔细评估可改变的风险因素可能会降低并发症发生率，同时允许肢体挽救。
