Applicability of Medial Sural Artery Perforator Flap in Patients with Diabetes with Peripheral Arterial Disease for Complex Lower Extremity Defects

Background: The objective of this study was to determine the applicability and reliability of the medial sural artery perforator (MSAP) flap in patients with diabetes with peripheral arterial disease (PAD) for lower extremity defects and to assess the effects of sacrificing the MSA on distal circulation. Patients and Methods: A radiologic and clinical study has been utilized to assess safety and applicability of MSA perforator flap in diabetics. Five diabetic patients operated for complex lower extremity defects were analyzed and radiological findings from 43 lower limbs of patients with diabetes previously subjected to angiography for PAD were analyzed. Age, duration of diabetes, concomitant complications and occluded vessel type, the diameter of MSA at the popliteal junction, the branching pattern, and the number of sizeable perforators were documented. Results: One total flap loss occurred, one donor side dehiscence occurred. All other flaps survived, and defects were successfully closed. Radiologically MSA was present in unoccluded form in all 43 diabetic patients. At least one sizeable perforator was observed in all patients. There was a statistically significant, but negative, correlation between the size of MSA and the occlusion of the popliteal artery. Conclusions: Diabetes solely is not a contraindication of MSAP flap usage, as MSA is not affected by PAD. However, perigenicular collateral hypertrophy through arteriogenesis can be an issue in patients with severe occlusion at the level of the popliteal artery, since MSA enlarges. Cases of MSA hypertrophy in the presence of PAD constitute a high risk; therefore, selection of another flap is recommended.