Foot Salvage with Selective Arterialization of Pedal Venosomes

Background: 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. Methods: 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. Results: 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. Conclusions: 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.