Combined free tissue transfer and infrainguinal bypass graft: An alternative to major amputation in selected patients

Objectives: The purpose of this study was to document outcome and adverse p rognostic factors in patients requiring combined free tissue transfer and d istal bypass grafting for otherwise nonreconstructible infrainguinal arteri al occlusive disease and advanced tissue necrosis. Methods: Between July 1990 and November 1999, 65 patients, all of whom woul d have required at least below-knee amputation, underwent free tissue trans fer in conjunction with infrainguinal bypass grafting at the University of Rochester. Preoperative variables were assessed for their influence on outc ome with chi (2) and outcome with life-table analysis with Cox proportionat e hazard testing. Results: Free tissue transfer was performed synchronously with arterial rec onstruction with autologous vein in 49 patients and after a previous functi oning venous bypass graft in 16 patients. The 30-day mortality rate was 5%, and major complications occurred in another 16% of patients. Flap location , weight-bearing status, preexisting osteomyelitis, and the timing of bypas s grafting relative to flap construction had no effect on outcome. All five free flap failures occurred within the first 30 days. All other flaps subs equently survived, even in seven patients whose bypass grafts thrombosed. F ive-year limb salvage and patient survival rates were 57% and 60%, respecti vely, and 65% of patients regained meaningful ambulation. The combination o f diabetes and dialysis-dependent renal failure was the strongest predictor of overall limb loss (P < .005; relative risk = 4.0), and diabetes alone w as the strongest predictor of death (P < .02; relative risk = 5.2). Conclusion: Free tissue transfer combined with infrainguinal bypass graftin g in selected patients is safe and effective. The combination of diabetes a nd chronic renal insufficiency, particularly the need for dialysis, is a po werful predictor of failure and should be considered a strong contraindicat ion for this procedure.