Outcomes of Split-Thickness Skin Grafting for Foot and Ankle Wounds in Patients With Peripheral Arterial Disease

Iram Naz, MD; Elliot T. Walters, MD; David E. Janhofer, BS; Morgan M. Penzler, BS; Eshetu A. Tefera, MS; Karen Kim Evans, MD; John S. Steinberg, DPM; Christopher E. Attinger, MD; Cameron M. Akbari, MD; Paul J. Kim, DPM, MS


Wounds. 2019;31(11):272-278. 

In This Article

Abstract and Introduction


Introduction: Tissue ischemia resulting from arterial insufficiency is a major factor affecting lower extremity wound healing in patients with peripheral arterial disease (PAD). Accelerated wound closure with split-thickness skin grafting (STSG) provides a durable barrier to infection and can prevent limb loss. Published STSG outcomes data are minimal in the post endovascular intervention population.

Objective: In this study, the authors examine factors predictive of STSG healing in patients with PAD following vascular intervention, including the effect of non-inline flow via arterial-arterial and non-arterial collateralization.

Materials and Methods: Patients with PAD and wounds of the foot and ankle who underwent STSG between January 2014 and December 2016 were retrospectively reviewed. All patients received angiographic evaluation and endovascular or open revascularization where necessary. Effects of extremity revascularizations, STSG percent take, and amputation rate were evaluated.

Results: Thirty-five patients with 47 wounds underwent STSG. There were 21 men and 14 women with a mean age of 64 ± 13 years. Revascularization was required in 23 patients (25 extremities) before STSG, with balloon angioplasty for tibial artery lesions as the most common revascularization. Patent pedal arch was present in 8 patients; 35 patients had an absent or incomplete pedal arch. Patients with a fully patent pedal arch healed at a significantly higher rate than those with an absent or incomplete pedal arch at 1 month (62.5% vs. 17.1%, P < .05). At 90-day follow-up, 9 of 35 (25.7%) patients with 9 of 47 (19.1%) wounds were lost to follow-up, leaving 18 of 38 (47.37%) wounds healed and 20 (52.63%) still open. Ultimately, 36 of 47 (76.60%) wounds healed and 6 major amputations in 6 patients were required at a mean 502 ± 342 days follow-up.

Conclusions: These results suggest the importance of arterial-arterial connections such as the pedal arch to the healing potential of foot and ankle wounds after STSG in this high-risk patient population.


About 8 million Americans over the age of 65 have peripheral arterial disease (PAD).[1] Due to the ever-increasing prevalence of diabetes and chronic kidney disease and an aging population, multilevel PAD and chronic total occlusions have become more common.[2,3] Critical limb ischemia (CLI) with advanced wound presentation is a major cause of nontraumatic lower extremity above-the-knee (AKA) and below-the-knee amputations (BKA). Such amputations are an expensive and catastrophic complication often leading to permanent disability and a concomitant decrease in functional status and quality of life.[4]

The goal for health care providers managing ischemic wounds is to expedite rapid and stable wound closure to create a durable protective barrier to further infection and limb loss. Wound closure can be achieved by conservative measures such as local wound care or by using split thickness grafting (STSG) and other surgical methods.[5] Split-thickness skin grafting requires local control of infection and a vascularized wound bed for success and is a relatively simple procedure, but literature on wound closure rates after STSG is limited in patients with PAD.[6–8]

This paper reports the outcomes of using STSG for lower extremity wound closure in patients with PAD. Patients underwent preoperative vascular evaluation and revascularization as needed. Factors predictive of complete wound healing after STSG (defined as 100% take) at 30 and 90 days were analyzed and compared with those in patients with less than 100% STSG take or persistent open wounds.