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

RAHUL KAPOOR

Journal of Plastic, Breast & Reconstructive Surgery·Peer-reviewed, open-access surgical case reportsPeer-reviewed · Open access

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 · JPBRS

Case report

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

RAHUL KAPOOR

Published May 28, 2026498 views7 min read

Export:RIS BibTeX

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

Key learning points

Pearls

patient willingness and appropriate counselling of all family members involved in patient care.
Adequate choice of flap.
Adequate immobilisation and anticoagulation. regular dressing to avoid pin track infection.
Proper post operative follow up to rule out development of discharging focus

Pitfalls

Development of pressure sore
Planter flexion and contracture
Development of osteoarthritis at ankle joint area.

Patient 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.

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 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.
Ankle joint stiff with foot and all five toes in planter flexion. passive dorsiflexion incomplete & difficult. There was loss of sensation in whole of foot and lower 2/3rd of leg with gross sensation of touch and decreased pain in upper 1/3 rd of leg. there was edema in whole of leg and foot. Pulsations could not be appreciated on examination in anterior tibial, dorsalis pedis and posterior tibial artery. Color doppler study showed
absence of flow in popliteal, posterior tibial artery stent and distally. Monophasic waveform in left anterior tibial artery. Colour doppler study right lower limb was normal. CT Angio showed The left CFA and SFA show normal course, caliber, and contrast enhancement. There was eccentric filling defect involving the proximal aspect of the left profunda femoris for a length of approximately 5 mm causing luminal narrowing by 50%-60%. The proximal left popliteal artery show good caliber and contrast enhancement. Distally, it show filling defect with near complete segmental occlusion. The origin of left anterior tibial artery as well as tibioperoneal trunk not visualized and re-formation of the posterior tibial and peroneal arteries with presence of multiple small collaterals. Dorsalis pedis artery is also not well visualised.

Pre-operative considerations

1. Patient willingness to save the limb, despite knowing all pros & cons of undergoing surgery for limb salvage.
2. Ipsilateral side anastomoses not feasible for two reasons.
A.Pulsation in posterior tibial artery on palpation could not be appreciated due to edema. On doppler study, posterior tibial not visualised. The posterior tibial artery was collapsed without any pulsations.
B.Proximally, the tissue was edematous and scarred and popliteal artery was too proximal to achieve suffficient lenght after vein loop anastomoses, to ensure availibility of flap for adequate wound cover.
So, decision to plan anastomosis of flap to unaffected limb was taken, with due consideration for external fixator application, immobilization of both limbs in one position, micro movement and shearing in anastomosis with high risk of bleeding and flap loss, along with ongoing high dose of anticoagulation regime. there was also risk of thrombosis in posterior tibial donor vessel with associated complications. chances of pressure sore at dependent heel area was always there. Despite all complications explained to patient, she was willing for Surgery.
Planned flap - 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.

References

The cross-leg free flap: A systematic review of the literature Karel-Bart Celie MD, Sarah Guo MD, Jessica Raya BS, Artur Fahradyan MD, Joseph Carey MD, Ara A. Salibian MD First published: 01 February 2024 https://doi.org/10.1002/micr.31144Digital Object Identifier (DOI)

How to cite this article

Related cases

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

Abstract

Key learning points

Patient history

Examination

Pre-operative considerations

References

Case 20 2026: Staged Excision and Delayed Primary Closure of a large Nodular Basal Cell Carcinoma of the Anterior Scalp

Case 22 2026: Superior Gluteal vessel: A rarely used recipient for free flap reconstruction of lumbosacral defects: a case report.

Case 23 2026: “Minimally Invasive Finger Amputation Using a Volar ‘Toilet seat’ Flap for Invasive Squamous Cell Carcinoma”

Step 1 — After serial debridement and VAC dressing

Step 2 — Cross leg Free latissimus dorsi muscle flap with split skin graft and limb fixed with external fixator

Step 3 — ETE Anastomoses of the thoracodorsal vein to the vena comitantes and ETS anastomoses of the GSV to the thoracodorsal vein

Step 4 — Flap detachment- 8 weeks post op after repeated conditioning with rubber tourniquet

Step 5 — FLAP POST DETACHMENT 6WEEKS AFTER

Step 6 — Pressure sore post detachment of cross leg free flap over left foot (affected extremity)

Step 7 — Pressure sore post detachment of cross leg free flap after 14 months managed conservatively ony with dressingd

Post-operative plan

Pearls

Pitfalls