Outcomes of combined vascular and flap reconstruction after lower extremity sarcoma resection involving major vessels

Background: Sarcoma resection involving major vascular structures of the extremities presents a complex surgical challenge. Limb preservation often requires immediate vascular reconstruction and soft tissue coverage to minimize complications, maintain functionality, and avoid secondary amputation. However, limited data exist on the outcomes of such combined procedures. The aim of this monocentric retrospective series study was to evaluate the early and midterm surgical and oncologic outcomes of immediate vascular and soft tissue reconstruction following sarcoma resection involving major limb vessels. Patients and methods: This retrospective study included consecutive patients undergoing en bloc resection of extremity soft tissue or bone sarcomas involving major vessels, followed by immediate vascular bypass and soft tissue flap reconstruction, at a single tertiary center between December 2019 and December 2024. Arterial and venous reconstructions used autografts or allografts; soft tissue coverage was achieved using free or pedicled flaps. Primary outcomes were limb salvage, flap survival, and bypass patency. Secondary outcomes included complications (Dindo–Clavien classification), wound healing time, and oncologic outcomes. Results: Seventeen patients (mean age, 50 years) underwent immediate vascular reconstruction (14 allografts, three autografts) and flap coverage (16 free flaps, one pedicled flap). R0 resection was achieved in 94%, with a 100% limb salvage rate, flap survival and vascular bypass patency. No local recurrences or secondary amputations occurred. At a mean follow-up of 26 months (range, 1–60 months), 35% developed distant metastases, and one patient (6%) died of disease progression. The overall complication rate was 100%, including 41% grade 3b and 30% grade 4a complications. Although 71% required reoperation for major complications, all limbs were ultimately preserved. Common complications included lymphedema (88%), lymphocele (76%), venous bypass thrombosis (65%), lymphorrhea (65%), operative site infection (65%), wound dehiscence (47%), arterial bypass stenosis (35%), and false-aneurysm rupture (30%). All wounds healed, with a mean healing time of 72 days. Univariate analysis identified operative site infection ( P = 0.005) and higher Dindo–Clavien grade ( P = 0.028) as factors significantly associated with venous bypass thrombosis. Conclusion: Combined immediate vascular and soft tissue reconstruction following sarcoma resection involving major vessels is a feasible and effective limb-salvage approach. Despite a high rate of early complications, satisfactory oncologic and functional outcomes can be achieved with a multidisciplinary surgical strategy.