Vascular Steal Phenomenon in Lower Extremity Reconstruction: A Review of Literature and Case Report

Introduction: Free tissue transfer is a well-described tool for complex lower extremity reconstruction in areas of local tissue paucity. Successful coverage of orthopedic hardware or exposed vital structures create opportunities for limb salvage. Methods: A retrospective chart review was performed of a patient sustaining a gunshot wound to the lower extremity with bony and soft tissue loss who underwent orthopedic fixation and free tissue transfer at the authors' institution with resultant distal extremity necrosis consistent with vascular steal phenomenon. A systematic literature review using preferred reporting items for systematic reviews and meta-analyses guidelines was performed using the keywords "free tissue transfer," OR "free flap," AND "vascular steal" on PubMed, Ovid/Medline, and Scopus. Results: After orthopedic fixation, a free anterolateral thigh flap anastomosed end-to-end with an already transected posterior tibial artery for soft tissue coverage. Despite a technically uncomplicated and successful reconstruction, the patient's postoperative course was complicated by steal syndrome, which ultimately led to distal forefoot necrosis and need for transmetatarsal amputation and secondary intention wound healing. Literature review of cases with similar vascular steal phenomenon after free tissue transfer yielded 6 studies totaling 10 patients. All patients with vascular steal phenomenon were previously diagnosed with diabetes and peripheral vascular disease. Despite a majority of single-vessel extremities receiving free tissue transfer with end-to-side techniques, outcomes after vascular steal universally resulted in amputation. Conclusions: Although vascular steal after free flap reconstruction is a documented phenomenon, this is the first recorded description of vascular steal syndrome from a ballistic-type mechanism in the trauma setting. Overall, this case and review of literature serves as a reminder of the tenuous nature of distal perfusion to the diseased extremity and prompts careful consideration during reconstruction to prevent high morbidity distal ischemia.