Surg Case Rep. 2026;12(1):26-0099. doi: 10.70352/scrj.cr.26-0099. Epub 2026 Apr 28.
ABSTRACT
INTRODUCTION: In chronic limb-threatening ischemia (CLTI), especially with diabetes and dialysis dependence, below-the-ankle arterial lesions and severe calcification often limit distal bypass options. While surgical distal venous arterialization (sDVA) can restore perfusion, achieving wound healing requires additional surgical strategies such as free flap transfer to provide adequate soft tissue coverage.
CASE PRESENTATION: A male patient in his 70s with diabetes and end-stage renal disease on hemodialysis presented with a right toe ulcer and rest pain. He had severe intradialytic hypotension and reduced cardiac function (ejection fraction: 22%) with multivessel coronary artery disease. Coronary artery bypass grafting (CABG) with 5 grafts was performed, and balloon angioplasty of the peroneal artery was added 53 days later to improve infrapopliteal perfusion. Cardiac function improved to an ejection fraction of 55% within 1 month, but the toe ulcer progressed to total toe gangrene. Six months later, the patient was readmitted with a deep foot infection. Despite the infection, lower limb muscle strength was preserved. sDVA was performed using a popliteal artery-posterior tibial vein bypass with the ipsilateral great saphenous vein, combined with sequential anastomosis to the diseased tarsal artery and Lisfranc-level amputation. Following sDVA, extensive debridement of infected tissue resulted in a large soft tissue defect. During the waiting period for definitive wound coverage, rheopheresis therapy using Rheocarna was administered to promote wound bed preparation. A free latissimus dorsi musculocutaneous flap was subsequently transferred to achieve wound closure. Four years after the initial intervention, the patient maintains favorable cardiac and limb function without ulcer recurrence.
CONCLUSIONS: We report a case of CLTI with below-the-ankle disease in a dialysis-dependent patient, successfully treated with CABG, endovascular therapy, rheopheresis therapy, sDVA, and free flap transfer. This case underscores the importance of combining revascularization and soft tissue reconstruction to achieve wound healing and preserve ambulatory function as key goals in managing complex below-the-ankle arterial lesions.
PMID:42100371 | PMC:PMC13148869 | DOI:10.70352/scrj.cr.26-0099