Staged matrix and micrografting reconstruction for no-option CLTI: A case report

Venous arterialization has emerged as a limb-salvage option for selected patients with no-option chronic limb-threatening ischemia, particularly those with type 2 diabetes, extensive pedal occlusive disease, and small artery disease (distal tibial and inframalleolar disease) in whom conventional bypass or endovascular revascularization is not an option. We present a case of a man in his late 70s with diabetes and severe distal occlusive disease who underwent endovascular venous arterialization for a threatened limb with gangrene, followed by staged wound reconstruction after open transmetatarsal amputation. Reconstruction was performed in a stepwise manner with serial debridement and wound-bed preparation, application of an Integra dermal regeneration template to augment granulation tissue formation, and subsequent Meek fractional skin grafting for definitive coverage. The wound healed over approximately 7 months, and the patient regained the ability to ambulate. This case highlights the concept that venous arterialization should be viewed not as an isolated revascularization maneuver, but as the perfusion-enabling stage of a broader reconstructive pathway in no-option limb salvage.