A 64-year-old man with unreconstructable aortoiliac atherosclerosis developed toe ulcers. The patient went through progressive levels of amputation, each complicated by further necrosis. Necrosis of the thigh amputation illustrates a prime dilemma in operating on severely ischemic parts. Suturing wounds and flaps creates tension which can diminish circulation. In the presence of prior hypoperfusion, the reduction is enough to kill tissue. However, you also cannot reliably leave the wound open, because highly ischemic tissues are intolerant of desiccation, bioburden, inflammation and injurious topical medicaments. This wound was sutured, and adjacent tissues died. If it is now simply debrided and left open, it will likely die some more. Most surgeons avoid this dilemma by simply doing a higher level amputation, but in this case, that option has run out.

Integra solves this dilemma, allowing one to debride the wound and then immediately close it without stress or tension on the tissues. By arresting inflammation, it controls yet another factor which threatens the ischemic wound. Seen here two weeks after debridement and Integra, the wound is healthy, and there is no necrosis at any of the margins. Because surgical revascularization was not possible, hyperbaric oxygen was used as an adjunct therapy for two weeks after Integra placement.

The Integra and skin grafts healed without problems, and the reconstruction remained stable.