Work

Bilateral Lateral Tarsal Artery Bypass and Free Flap Reconstruction of an Infected Gangrenous Heel in Chronic Limb-Threatening Ischemia: A Case Report of Three-Year Functional Limb Salvage

Year: 2026

Type: article

Abstract: INTRODUCTION: Distal bypass for chronic limb-threatening ischemia (CLTI) is technically demanding when the conventional pedal arteries are unavailable, and revascularization alone seldom heals an extensive heel defect. CASE PRESENTATION: A man in his 60s receiving maintenance hemodialysis presented with bilateral CLTI and gangrene of the left heel after failed endovascular therapy, and bilateral major amputations had been considered before referral. Both limbs were classified as Wound, Ischemia, and foot Infection clinical stage 4. Diffuse calcification of the infrapopliteal and pedal arteries left the lateral tarsal artery (LTA) as the only suitable distal target, and bilateral superficial femoral artery-to-LTA bypasses were performed with in situ great saphenous vein grafts under nerve block anesthesia. Because repeated debridement left the calcaneus exposed, a free latissimus dorsi musculocutaneous flap anastomosed to the left bypass graft was transferred and covered with a split-thickness skin graft. The wounds healed after minor amputations, and the patient regained independent ambulation. An ulcer subsequently developed on the weight-bearing surface of the transferred flap and never healed despite pressure-relieving insoles and additional inflow angioplasty; nevertheless, the flap remained viable, both grafts remained patent, and ambulatory function was preserved until the patient died of an unrelated cause 3 years after revascularization. CONCLUSIONS: The LTA can serve as a distal bypass target when the conventional pedal arteries are unavailable, and, when combined with free flap reconstruction, it may achieve long-term functional limb salvage despite extensive heel gangrene. The reconstructed weight-bearing heel nevertheless remains prone to ulceration that may not heal, so preventive off-loading and long-term surveillance are essential.

Source: Surgical Case Reports

DOI: 10.70352/scrj.cr.26-0684