Steal Syndrome in Free Flap Microvascular Reconstruction of the Lower Extremity: Systematic Review of Incidence, Risk Factors, and Surgical Management
Abstract
1. Introduction
2. Materials and Methods
2.1. Guidelines and Ethics
2.2. Literature Search
- Terms related to free flap microvascular reconstruction: “Free Tissue Flaps,” “Microvascular Surgery,” “Microanastomosis,” “ Microvascular Reconstruction,” “Free Flap,” and “Free Tissue Graft.”
- Terms related to steal syndrome: “Steal Phenomenon,” “Steal Syndrome,” “Arterial Steal,” “Vascular Steal,” and “Subclavian Steal Syndrome.”
- Search operators were applied to refine results, such as steal NEXT/1 (syndrome* OR phenomenon*)) OR ((arter* OR vascular OR Subclavian) NEXT/1 steal).
2.3. Study Selection
- Clinical studies investigating the presence of steal syndrome in free flap microvascular reconstruction of the lower extremities.
- Studies reporting quantitative or qualitative data on steal syndrome, including predictors, implicated flaps, and recipient vessels.
- Prospective, retrospective, observational studies, case series, and case reports providing relevant data.
- Studies published in English.
- Animal studies or in vitro research.
- Studies focusing on non-free flaps (e.g., pedicled flaps), or reporting the occurrence of steal syndrome unrelated to free flap surgery.
- Studies without clinical relevance or those failing to report outcomes related to steal syndrome.
- Non-English language studies without available translations.
3. Quality Assessment and Risk of Bias
Statistical Analysis
4. Results
4.1. Study Selection
4.2. Study Characteristics
4.3. Patient Demographics
4.4. Clinical Characteristics
4.5. Microvascular Reconstruction Characteristics
4.6. Steal Syndrome Occurrence and Management
4.7. Risk of Bias and Level of Evidence
5. Discussion
6. Limitations
7. Conclusions
Supplementary Materials
Funding
Institutional Review Board Statement
Informed Consent Statement
Acknowledgments
Conflicts of Interest
References
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Study | Journal | Study Design | Country | Patients | Number of Flaps | Level of Evidence |
---|---|---|---|---|---|---|
Sonntag et al., 1995 [22] | Annals of Plastic Surgery | USA | Retrospective case series | 3 | 3 | IV |
Musser et al., 1995 [23] | European Journal of Plastic Surgery | USA | Case report | 1 | 1 | V |
Rainer et al., 2003 [24] | Journal of Reconstructive Microsurgery | Austria | Retrospective case series | 9 | 10 | IV |
Study | Mean Age (±SD) | Indication | Flap Type | Number of Patients Developing Steal Syndrome | Patient Comorbidities | Vascular Pedicle | Recipient Vessel |
---|---|---|---|---|---|---|---|
Sonntag et al., 1995 [22] | 69.67 ± 4.04 | Non-healing heel ulcer and necrosis of the 5th toe, non-healing heel ulcer, non-healing heel ulcer, and exposed Achilles tendon | LD (2) and rectus abdominis (1) | 3 | HTN, DM, PVD, and RF | Thoracodorsal and inferior epigastric | Popliteal (3) |
Musser et al., 1995 [23] | 73 | Non-healing forefoot ulcer | LD | 1 | HTN, DM, and PVD | Thoracodorsal | Anterior tibial |
Rainer et al., 2003 [24] | 54.3 ± 9.37 | Diabetic foot ulcer | LD (2) and gracilis (1) | 3 | DM, HTN, PVD, and PN | Thoracodorsal, medial circumflex femoral | Anterior tibial (1) and dorsal pedis (2) |
Study | Anastomotic Configuration | Artery Inflow (Recipient Artery) | Venous Outflow (Single/Double Vein Anastomosis) | Vein Graft Used (Yes/No) |
---|---|---|---|---|
Sonntag et al., 1995 [22] | End-to-side | Reverse vein graft between the LD and popliteal artery, vein graft used on PTFE graft between the deep femoral artery and popliteal artery, and vein graft between the popliteal artery and dorsal pedis | Popliteal vein (single vein) | Saphenous vein |
Musser et al., 1995 [23] | End-to-side | Saphenous vein graft between the superficial femoral to the proximal anterior tibial | Posterior tibial vein (single vein) | Cephalic vein |
Rainer et al., 2003 [24] | Flow-through and end-to-side | Anterior tibial | Anterior tibial (single vein) | No |
Study | Patients with Steal Syndrome | Salvage Intervention | Follow-Up (Months) |
---|---|---|---|
Sonntag et al., 1995 [22] | 3 | Not attempted, BKA | Not mentioned |
Musser et al., 1995 [23] | 1 | Not attempted, BKA | Not mentioned |
Rainer et al., 2003 [24] | 3 | Anastomotic revision of venous thrombosis (post-op day 4), debridement (post-op day 22), | 37.7 ± 4.6 |
Chopart’s amputation due to progressive ischemic necrosis of the remaining toes (after post-op day 22), | |||
and debridement of peripheral necrosis (post-op day 58 and 64) |
Domain for Evaluating the Methodological Quality of Case Reports and Case Series | ||||||||
---|---|---|---|---|---|---|---|---|
Selection | Ascertainment | Causality | Reporting | |||||
Reference | Q.1 | Q.2 | Q.3 | Q.4 | Q.5 | Q.6 | Q.7 | Q.8 |
Sonntag et al., 1995 [22] | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
Musser et al., 1995 [23] | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
Rainer et al., 2003 [24] | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
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Karamitros, G.; Iliadis, I.; Pensy, R.A.; Lamaris, G.A. Steal Syndrome in Free Flap Microvascular Reconstruction of the Lower Extremity: Systematic Review of Incidence, Risk Factors, and Surgical Management. Bioengineering 2025, 12, 647. https://doi.org/10.3390/bioengineering12060647
Karamitros G, Iliadis I, Pensy RA, Lamaris GA. Steal Syndrome in Free Flap Microvascular Reconstruction of the Lower Extremity: Systematic Review of Incidence, Risk Factors, and Surgical Management. Bioengineering. 2025; 12(6):647. https://doi.org/10.3390/bioengineering12060647
Chicago/Turabian StyleKaramitros, Georgios, Ilias Iliadis, Raymond A. Pensy, and Gregory A. Lamaris. 2025. "Steal Syndrome in Free Flap Microvascular Reconstruction of the Lower Extremity: Systematic Review of Incidence, Risk Factors, and Surgical Management" Bioengineering 12, no. 6: 647. https://doi.org/10.3390/bioengineering12060647
APA StyleKaramitros, G., Iliadis, I., Pensy, R. A., & Lamaris, G. A. (2025). Steal Syndrome in Free Flap Microvascular Reconstruction of the Lower Extremity: Systematic Review of Incidence, Risk Factors, and Surgical Management. Bioengineering, 12(6), 647. https://doi.org/10.3390/bioengineering12060647