Case 06 2026: Post-Embolic Gangrene of the Left Lower Limb Managed with Serial Debridement, VAC Therapy, and Cross-Leg Free Flap Reconstruction for Limb Salvage

Keywords: Rheumatic Heart Disease, Embolism, Gangrene, Limb Salvage, Vessel-Depleted Extremity, Cross Leg Free Flap Authors: DR RAHUL KAPOOR Abstract Limb salvage in a vessel-depleted extremity remains a formidable reconstructive challenge. We report a case of extensive lower limb gangrene following popliteal artery embolism in a patient with rheumatic heart disease and mitral stenosis. The defect involved exposed bone, necrotic tendons, and absent distal perfusion, with ipsilateral recipient vessels unsuitable for microvascular anastomosis. A cross-leg free flap with external fixation was performed using contralateral posterior tibial vessels. Venous congestion required supercharging with great saphenous vein anastomosis. The postoperative course was uneventful. Flap division at eight weeks demonstrated successful neovascularization, achieving durable limb salvage with progressive sensory and perfusion recovery at 18 months follow-up. Patient medical history Known case of Rheumatic Heart Disease with Mitral Stenosis. Patient developed complain of pain in left leg and foot, in June, 2024. Peripheral Angiography showed 80-90% occluded left external iliac artery & left popliteal artery and 100% left posterior tibial artery. Thrombolysis and plain old balloon Angioplasty done after 3 days of development of pain. Revascularization procedure was followed by development of compartment syndrome in left leg and foot and fever, with progressive discoloration of skin over lower half of leg, ankle and dorsum of foot. Discolouration turned into open wound with complete loss of skin cover, necrosed tendons and exposed bones of lower half of leg, ankle joint and proximal half of dorsum of foot. wound was heavily infected with pus discharge and foul smell. Before and After Patient examination there was progressive discoloration of skin over lower half of leg, ankle and dorsum of foot. Discoloration turned into open wound with complete loss of skin cover, necrosed tendons and e