Arteriovenous Loops Enable Free Tissue Transfer With Otherwise Inadequate Local Donor and Recipient Vessels

Case 1: A 72-year old male patient with diabetes mellitus was admitted with severe cellulitis of the right lower extremity (A). Angiography showed severe atherosclerosis with only patent anterior tibial artery (B). After serial debridement, an arteriovenous loop (30 cm) was performed and anastomosed to the popliteal vessels. After 15 days, a free latissimus dorsi muscle was used for reconstruction (C). Distal flap necrosis occurred, requiring debridement and reconstruction using a permanent skin substitute (Integra) and skin graft three months later. After a follow-up of 23 months, stable soft tissue coverage was achieved (D).

Case 2: A 67-year old male patient with diabetes mellitus was admitted with a soft tissue defect over the medial malleolus with osteomyelitis (A). Angiography showed severed atherosclerosis with severe stenosis of the anterior tibial artery (B). After serial debridement, an arteriovenous loop using the great saphenous venous was performed and anastomosed to the popliteal artery and concomitant tibial vein (loop length 32 cm). The free gracilis muscle was used for reconstruction seven days later. Intraoperative Indocyanine green (ICG) - enhanced fluorescence showed good perfusion of the flap (C). Due to a burn injury five months later, transmetatarsal amputation I-III was required. After a follow-up of 13 months, stable soft tissue coverage was observed over the medial malleolus (D).