Reconstructive Surgical Management of Vasopressor-Ischemia Related Distal Extremity Loss.

Introduction: In the critically ill patient with severe sepsis and persistent hypotension, mitigating ischemia to the distal extremities is often not the priority. However, when vasopressor-induced ischemia leads to partial distal extremity loss, this can present a complex reconstructive challenge.

Case Report: We present a case of reconstructive surgical management of multiple distal extremity loss induced by prolonged vasopressor use for treatment of septic shock, with thumb reconstruction through pollicization of a partially amputated index finger and foot salvage using a free neurotized anterolateral thigh (ALT) flap for sensate reconstruction. A 48-year-old male with a history of septic shock requiring prolonged vasopressors presented with dry gangrenous partial loss of the upper and lower extremities, including loss of his left thumb at the metacarpal and right foot at the Lisfranc level. Thumb reconstruction was completed with pollicization, which involved transferring the remaining index finger to the thumb position, and a reverse radial forearm flap to cover the resulting webspace defect. Despite good reverse flow through the radial artery, the distal-most flap did not survive, requiring placement of an acellular dermal matrix (Integra), and an eventual full thickness skin graft. The lower extremity required a combined approach with orthopedics, who performed a Lisfranc amputation, Achilles lengthening, and tendon transfer, followed by free neurotized fasciocutaneous ALT flap with neurotization using the lateral femoral cutaneous nerve coapted to the medial plantar nerve and a medial femoral sensory branch coapted to the tibial nerve.

Conclusion: This case demonstrates an approach for reconstruction of prehensile function and sensate foot salvage following vasopressor-induced distal loss of multiple extremities, with a focus on specific challenges and pitfalls.