Diabetic Foot Preservation in End-Stage Renal Disease with Combined Angioplasty and Free Flap Reconstruction

Introduction: Diabetic foot disease is a significant global health, often leading to poor wound healing and a higher risk of lower-extremity amputation. These challenges are exacerbated in diabetic patients with end-stage renal disease (ESRD). Currently there is limited evidence on the long-term efficacy of combined angioplasty and free flap reconstruction for limb preservation in the diabetic-ESRD population. We report the long-term outcomes of this limb preservation approach. Materials and Methods: A retrospective cohort study of diabetic patients on hemodialysis with peripheral arterial occlusive disease and soft tissue defects in the foot was conducted. Patients who underwent endovascular revascularization followed by free flap reconstruction for lower limb preservation at Dalin Tzu Chi General Hospital, Taiwan, from January 2010 to January 2022 were included. The primary objective was to report outcomes of this cohort. The secondary objective was to identify risk factors for flap loss, lower limb amputation, and mortality. Results: We analyzed 40 legs in 35 patients who underwent the combined procedure. The median follow-up was 559.5 days. Flap success rate was 92.5%. The one-, two-, and five-year limb preservation rates were 97%, 91.9%, and 83.5%, respectively. Patient survival rates at one, two, and five years were 65%, 46%, and 21.6%. Age (p=0.043), smoking history (p=0.026), and cerebrovascular accident history (p=0.0003) were associated with higher risks of major limb amputation. Conclusion: Free flap reconstruction for diabetic foot in ESRD patients is reliable with a high limb preservation rate. However, this may not translate to improved patient survival over a 5-year period.