THE IMPACT OF VARIOUS FACTORS ON THE ENGRAFTMENT OF FREE MUSCLE FLAPS DURING INDIRECT REVASCULARIZATION OF THE LOWER LIMBS IN PATIENTS WITH CRITICAL LIMB ISCHEMIA

Highlights

When direct revascularization of the limb, either open or endovascular, is not feasible in patients with critical limb ischemia, these patients are often destined to undergo major limb amputation, which is associated with high rates of postoperative disability and mortality. Various indirect revascularization techniques have been proposed as alternatives to major amputation in this patient population, one of which is free flap transfer to the ischemic area. Subsequently, the flap becomes integrated into the ischemic tissues of the limb, enhancing local perfusion and thereby contributing to the gradual relief of critical ischemia. However, despite the advantages of this approach, the procedure is technically demanding and, in a subset of patients, is complicated by early perioperative flap loss. The present study attempts to analyze factors associated with early perioperative flap survival in patients with different etiologies of arterial disease and to propose preventive measures.

Aim. To analyze various factors affecting the survival of free flaps in the early postoperative period. Based on the analysis of these factors, to propose methods for preventing early postoperative flap failure and to refine patient selection criteria.

Methods. A retrospective analysis was performed of medical records from 39 patients (10 with thromboangiitis obliterans (Buerger’s disease), 16 with diabetes mellitus, and 13 with atherosclerosis) operated between 2016 and 2025, who underwent lower limb revascularization using a free muscle flap (gracilis or latissimus dorsi). Age, laboratory parameters (Hb, protein, creatinine), presence of infection and spectrum of pathogens, as well as outcomes in terms of flap survival or necrosis were assessed.

Results. The overall free muscle flap engraftment rate was 64.1% (25 out of 39 patients). Flaps failed more frequently in older patients (66.8 ± 13.4 years, p = 0,0075). In patients with diabetes mellitus, flap necrosis occurred more often (62.5%), mainly associated with wound infection or flap vessel compromise. In the Buerger’s disease group, the engraftment rate was maximal (90%). Similar pathogens of wound infection were observed across all patient groups, with no correlation between specific pathogens and flap loss. No significant associations were found between laboratory parameters and flap failure.

Conclusion. Further investigation of this technique is warranted, particularly in patients with diabetes mellitus. Monitoring glycated hemoglobin as a long-term marker of wound immune dysfunction and microangiopathy, and postponing surgery until target values are achieved, may improve outcomes in this patient group. To enhance flap survival and the success of revascularization, a comprehensive approach is required, including careful patient selection, optimization of comorbidities and aggressive management of wound infection.

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