Microvascular distal foot arterialization with flow through free flaps for salvage of the no-option foot

Patients with chronic limb-threatening ischemia, advanced foot wounds, and no pedal revascularization targets often face amputation. Deep vein arterialization has significant drawbacks. We report three cases using flow-through free flaps with microvascular distal foot arterialization to salvage ischemic feet with complex wounds. All flaps survived. Patients achieved wound healing and ambulation. Two maintained perfusion at 3 and 6 years. One required transmetatarsal amputation at 14 months but remains ambulatory. This technique provides a novel salvage option for the "no-option" foot by combining soft tissue coverage and selective arterialization of small distal veins, avoiding complications of deep vein arterialization and offering durable perfusion.