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Peer-reviewedCC BY 4.0Surgical Case Reports

Bilateral Lateral Tarsal Artery Bypass and Free Flap Reconstruction of an Infected Gangrenous Heel in Chronic Limb-Threatening Ischemia: A Case Report of Three-Year Functional Limb Salvage

  • Noriyuki Yokoyama1
  • Shinsuke Kikuchi1
  • Hirofumi Jinno1
  • Takayuki Uramoto1
  • Kazuki Takahashi1,2
  • Keisuke Kamada1
  • Takamitsu Tatsukawa1
  • Uran Moriyama3
  • Yuri Yoshida1
  • Ranko Hinooka4
  • Takanori Fujiki5
  • Nobuyoshi Azuma1,2
5 affiliations
  1. 1Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
  2. 2Department of Chronic Limb-Threatening Ischemia Research, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
  3. 3Department of Plastic and Reconstructive Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
  4. 4Department of Nursing, Asahikawa Medical University Hospital, Asahikawa, Hokkaido, Japan
  5. 5Dialysis Center, Japanese Red Cross Shimizu Hospital, Kamikawa-gun, Hokkaido, Japan
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Abstract

INTRODUCTION: Distal bypass for chronic limb-threatening ischemia (CLTI) is technically demanding when the conventional pedal arteries are unavailable, and revascularization alone seldom heals an extensive heel defect.

CASE PRESENTATION: A man in his 60s receiving maintenance hemodialysis presented with bilateral CLTI and gangrene of the left heel after failed endovascular therapy, and bilateral major amputations had been considered before referral. Both limbs were classified as Wound, Ischemia, and foot Infection clinical stage 4. Diffuse calcification of the infrapopliteal and pedal arteries left the lateral tarsal artery (LTA) as the only suitable distal target, and bilateral superficial femoral artery-to-LTA bypasses were performed with in situ great saphenous vein grafts under nerve block anesthesia. Because repeated debridement left the calcaneus exposed, a free latissimus dorsi musculocutaneous flap anastomosed to the left bypass graft was transferred and covered with a split-thickness skin graft. The wounds healed after minor amputations, and the patient regained independent ambulation. An ulcer subsequently developed on the weight-bearing surface of the transferred flap and never healed despite pressure-relieving insoles and additional inflow angioplasty; nevertheless, the flap remained viable, both grafts remained patent, and ambulatory function was preserved until the patient died of an unrelated cause 3 years after revascularization.

CONCLUSIONS: The LTA can serve as a distal bypass target when the conventional pedal arteries are unavailable, and, when combined with free flap reconstruction, it may achieve long-term functional limb salvage despite extensive heel gangrene. The reconstructed weight-bearing heel nevertheless remains prone to ulceration that may not heal, so preventive off-loading and long-term surveillance are essential.

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Cite

BibTeXRIS
BibTeX
@article{yokoyama2026bilateral,
  title = {{Bilateral Lateral Tarsal Artery Bypass and Free Flap Reconstruction of an Infected Gangrenous Heel in Chronic Limb-Threatening Ischemia: A Case Report of Three-Year Functional Limb Salvage}},
  author = {Noriyuki Yokoyama and Shinsuke Kikuchi and Hirofumi Jinno and Takayuki Uramoto and Kazuki Takahashi and Keisuke Kamada and Takamitsu Tatsukawa and Uran Moriyama and Yuri Yoshida and Ranko Hinooka and Takanori Fujiki and Nobuyoshi Azuma},
  journal = {Surgical Case Reports},
  year = {2026},
  month = oct,
  doi = {10.70352/scrj.cr.26-0684},
  url = {https://doi.org/10.70352/scrj.cr.26-0684},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Bilateral Lateral Tarsal Artery Bypass and Free Flap Reconstruction of an Infected Gangrenous Heel in Chronic Limb-Threatening Ischemia: A Case Report of Three-Year Functional Limb Salvage
AU  - Noriyuki Yokoyama
AU  - Shinsuke Kikuchi
AU  - Hirofumi Jinno
AU  - Takayuki Uramoto
AU  - Kazuki Takahashi
AU  - Keisuke Kamada
AU  - Takamitsu Tatsukawa
AU  - Uran Moriyama
AU  - Yuri Yoshida
AU  - Ranko Hinooka
AU  - Takanori Fujiki
AU  - Nobuyoshi Azuma
PY  - 2026
DA  - 2026/10/31
JO  - Surgical Case Reports
DO  - 10.70352/scrj.cr.26-0684
UR  - https://doi.org/10.70352/scrj.cr.26-0684
AB  - INTRODUCTION: Distal bypass for chronic limb-threatening ischemia (CLTI) is technically demanding when the conventional pedal arteries are unavailable, and revascularization alone seldom heals an extensive heel defect.  CASE PRESENTATION: A man in his 60s receiving maintenance hemodialysis presented with bilateral CLTI and gangrene of the left heel after failed endovascular therapy, and bilateral major amputations had been considered before referral. Both limbs were classified as Wound, Ischemia, and foot Infection clinical stage 4. Diffuse calcification of the infrapopliteal and pedal arteries left the lateral tarsal artery (LTA) as the only suitable distal target, and bilateral superficial femoral artery-to-LTA bypasses were performed with in situ great saphenous vein grafts under nerve block anesthesia. Because repeated debridement left the calcaneus exposed, a free latissimus dorsi musculocutaneous flap anastomosed to the left bypass graft was transferred and covered with a split-thickness skin graft. The wounds healed after minor amputations, and the patient regained independent ambulation. An ulcer subsequently developed on the weight-bearing surface of the transferred flap and never healed despite pressure-relieving insoles and additional inflow angioplasty; nevertheless, the flap remained viable, both grafts remained patent, and ambulatory function was preserved until the patient died of an unrelated cause 3 years after revascularization.  CONCLUSIONS: The LTA can serve as a distal bypass target when the conventional pedal arteries are unavailable, and, when combined with free flap reconstruction, it may achieve long-term functional limb salvage despite extensive heel gangrene. The reconstructed weight-bearing heel nevertheless remains prone to ulceration that may not heal, so preventive off-loading and long-term surveillance are essential.
SN  - 2198-7793
ER  -