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
Dr. RAHUL KAPOOR
Abstract
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
BeforeAfterKnown 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.
Serial debridement of infected and dead tendons and necrotic tissue before each successive VAC application under proper antibiotic cover and splintage
After 4 to 5 sittings of VAC dressings, patient was planned for final debridement under GA & flap cover
Due consideration was given for Free latissimus dorsi muscle flap with split skin graft. LD flap is broad flap with adequate length of pedicle and proximal muscle cuff to cover the pedicle and prevent its shear. Skin incision extended proximally to the junction of the proximal and middle thirds of the leg with debridement of dead and infected tissue - tendons and muscles under the covered area was done without tourniquet. Flap insetting was performed with two limbs of 18 G romovac drains placed from either side for wound irrigation and flap insetting done. Fixator application followed by vessel anastomosis
2
The thoracodorsal artery end-to-end anastomoses are performed on the posterior tibial artery, and thoracodorsal vein end-to-end anastomoses are performed on the vena comitantes.
The flap started showing signs of venous congestion; therefore, an additional anastomosis, the end of the great saphenous vein, was dissected out and delivered through the same anastomotic (posterior tibial) area and was anastomosed to the side of the thoracodorsal vein in an end-to-end fashion (proximal to end-to-end anastomoses with vena comitantes)
3
Recovery - uneventful
Anticoagulation regimen - to maintain an INR between 1.5 - 2.5
wound bed irrigation done through - Romovac drain , which was continued for 3 weeks after surgery
Flap detachment was planned after 6 weeks, with intermittent compression was applied to the pedicle
ICG showed signs of vascularization from the wound bed with a tourniquet around the pedicle.
The patient did not show signs of flap ischemia, even at the distal end, suggesting good perfusion from the wound bed
The patient was discharged on the advice of physiotherapy, partial weight-bearing, and compression garments.
4
There was uneventful healing and no necrosis either at distal most flap end or in the detached flap pedicle site. there was no flap debulking done.
5
Pressure sore developed over heel area due to absence of any sensation.
it appeared to be full thickness in nature
6
Pressure sore developed over heel area due to absence of any sensation. With gradual returning of sensation, pressure sore healed well without any surgical intervention.
7
Physiotherapy,
Massage
Ambulation and weight bearing - gradual and progressive over affected limb
How to cite this article
Dr. RAHUL KAPOOR. 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. Journal of Plastic, Breast & Reconstructive Surgery. 2026.
Open access. © 2026 The Author(s). Published by the Journal of Plastic, Breast & Reconstructive Surgery. Copyright to this case is shared between the author(s) and the journal; authors may reuse their own case for education, presentations and social media.
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