• Erkki Tukiainen, M Kallio, and M Lepäntalo.
• Department of Plastic Surgery, Helsinki University Central Hospital, Helsinki, Finland. erkki.tukiainen@hus.fi
• Ann. Surg. 2006 Dec 1; 244 (6): 949958949-57; discussion 957-8.

ObjectiveTo assess long-term outcome and prognostic factors for extreme surgery by vascular and plastic surgical teamwork for leg salvage in patients with critically ischemic large tissue defects.Summary Background DataCombined vascular reconstruction and microvascular free-flap transfer has been used to improve distal perfusion and cover large tissue defects caused by the critical limb ischemia (CLI) in few dedicated centers during the past 15 years. Comorbidities compromise the results of these demanding operations, and it is unclear how far this mode of treatment should be extended.MethodsDuring 1989 to 2003, altogether 2157 vascular or endovascular revascularizations for CLI manifested as tissue lesions were performed. These included 81 revascularizations combined with microvascular free flap transfers in 79 patients (37-85 years). All the patients were candidates for major amputation. The patients were followed up at least 2 years or to death (mean follow-up, 62 months; SD, +/-34 months).ResultsOne- and 5-year leg salvage rates were 73% and 66%, survival rates 91% and 63%, and amputation-free survival rates of 70% and 41%, respectively. Male gender and American Society of Anesthesiologists score 4 were associated with an increased risk of death, whereas the involvement of the heel mostly with calcaneal osteomyelitis and a large size of defect predicted major amputation.ConclusionsA combined vascular reconstruction and free-flap transfer offers an option for advanced limb salvage in a selected group of patients with CLI and a major tissue defect. Poor general condition, the involvement of the heel, and a large defect would indicate an amputation over extreme attempts for limb salvage.

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