Revaskularisation vor Defektdeckung – essenzielle Schnittstelle zwischen plastischer Chirurgie und Gefäßchirurgie

Zusammenfassung

Komplexe, ischämische Wunden im Bereich der unteren Extremität mit freiliegenden tiefen Strukturen stellen große Herausforderungen an die behandelnden Fachdisziplinen dar. Als Alternative zur Majoramputation ergibt sich für ausgewählte Patienten die Möglichkeit eines kombinierten Verfahrens mittels arterieller Rekonstruktion und nachfolgender mikrochirurgischer Defektdeckung durch eine freie Lappentransplantation. Als arterielle Rekonstruktionsverfahren stehen endovaskuläre oder offen chirurgische Verfahren wie Bypassrekonstruktion oder Implantation eines arteriovenösen Loops als Vorbereitung für die Defektdeckung zur Verfügung. Ziel der arteriellen Rekonstruktion ist die Schaffung einer ausreichenden Perfusion zur Defektdeckung an der Extremität sowie die Schaffung von Anschlussgefäßen für die Lappentransplantation. Die Auswahl des Lappens richtet sich u. a. nach der Größe und Ausdehnung des Defektes sowie nach dem Vorhandensein einer Osteomyelitis. Dies kann ein- oder zweizeitig erfolgen. In Zentren ist dieses kombinierte Vorgehen als sichere Methode etabliert. Die Mikroperfusionsanalyse des Gewebes mittels Indocyaningrün erhöht nochmals die Sicherheit des Verfahrens und kann Perfusionsdefizite aufzeigen. Das kombinierte Verfahren mittels arterieller Rekonstruktion und freiem Gewebetransfer liefert gute Langzeitergebnisse im Hinblick auf amputationsfreies Überleben und postoperative Mobilität. Wichtig für die Indikationsstellung ist eine korrekte Patientenselektion unter Berücksichtigung der Kontraindikationen. Dieses Verfahren sollte für alle mobilen Patienten mit komplexen Weichteildefekten vor einer Majoramputation evaluiert werden.

Abstract

Treatment of complex ischemic lower leg defects with exposure of deep anatomic structures represents a considerable challenge to involved specialties. In selected patients, limb salvage can be achieved as an alternative to major amputation by means of a combined approach including arterial reconstruction and subsequent free flap transfer. Arterial reconstruction can be performed either by endovascular or open surgical treatment (bypass reconstruction or implantation of an arteriovenous loop) preliminary to defect reconstruction using microsurgical free flap transplantation. Whereas the aim of the arterial reconstruction comprises the establishment of sufficient perfusion and creation of adequate target vessels for the free flap transfer, the selection of the appropriate flap entity depends on the extent of the wound as wells as on the presence of osteomyelitis. Arterial reconstruction and defect reconstruction can be performed as one-stage or two-stage procedure and has become an established and feasible treatment approach in centers. Evaluation of microperfusion by means of indocyanine green can further increase safety and feasibility of this method. Against this background, combined arterial reconstruction and subsequent free flap transfer provides excellent results in terms of amputation free survival and postoperative mobility. Essential is however an individualized decision making in consideration of patient selection and possible contraindications. This approach may be evaluated in mobile patients with complex wounds prior to major amputation.

Schlüsselwörter

Bypass-Chirurgie - distale Bypass-Chirurgie - endovaskulär - freier mikrochirurgischer Gewebetransfer - Gefäßchirurgie - kombinierte Operation

Keywords

bypass surgery - distal bypass surgery - endovascular - free microsurgical tissue transfer - combined operation/surgical intervention - vascular surgery

Publication History

Received: 03 April 2023

Accepted after revision: 27 September 2023

Article published online:
13 November 2023

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