{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,17]],"date-time":"2026-04-17T14:39:06Z","timestamp":1776436746621,"version":"3.51.2"},"reference-count":40,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2025,6,12]],"date-time":"2025-06-12T00:00:00Z","timestamp":1749686400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Bioengineering"],"abstract":"<jats:p>Background: Steal syndrome in the setting of microvascular reconstruction refers to a phenomenon whereby blood flow is diverted from the native tissue to the free flap, leading to ischemia and potential limb loss. In the present study, we aim to comprehensively evaluate the occurrence and management of steal syndrome in free flap reconstruction of the lower extremities. Methods: A thorough literature search was conducted across the MEDLINE, Embase, Cochrane Library, and Scopus databases up to 29 January 2025. Studies were selected based on predefined inclusion criteria focusing on free flap microvascular reconstruction in the lower extremities with a focus on steal syndrome. Two independent reviewers assessed and extracted data. Results: Three studies were included, involving seven patients, with a mean age of 65.66 \u00b1 5.89 years, who developed steal syndrome following free flap microvascular reconstruction. The most common revision involved below-the-knee amputation (BKA) due to ischemic complications. Comorbidities such as peripheral vascular disease (PVD), diabetes, and hypertension were present in all cases. The majority of anastomoses (85.7%) were end-to-side (ETS), with only one case utilizing a flow-through configuration. The majority of cases (n = 5, 71.4%) were reconstructed using latissimus dorsi (LD) flaps, with the remaining two cases using rectus abdominis (n = 1) and gracilis (n = 1) flaps. The recipient vessel was the anterior tibial artery in two patients (28.6%), the dorsalis pedis artery in two patients (28.6%), and the popliteal artery in three patients (42.9%). The most common salvage procedure was below-the-knee amputation (BKA), performed in four patients (57.1%). One patient required revision of the venous anastomosis and flap debridement, followed by a Chopart amputation (n = 1, 14.3%). Conclusions: The occurrence of steal syndrome in free flap microvascular reconstruction of the lower extremities is rare but can lead to significant complications, including amputation. The findings indicate that steal syndrome is more likely in patients with pre-existing vascular conditions such as PVD and diabetes. While surgical technique and flap type may influence its development, further studies are needed to identify specific anatomical and clinical predictors. The absence of a unified treatment guideline underscores the need for further investigation into effective management strategies to prevent amputation and optimize patient outcomes.<\/jats:p>","DOI":"10.3390\/bioengineering12060647","type":"journal-article","created":{"date-parts":[[2025,6,12]],"date-time":"2025-06-12T06:42:48Z","timestamp":1749710568000},"page":"647","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Steal Syndrome in Free Flap Microvascular Reconstruction of the Lower Extremity: Systematic Review of Incidence, Risk Factors, and Surgical Management"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2208-8539","authenticated-orcid":false,"given":"Georgios","family":"Karamitros","sequence":"first","affiliation":[{"name":"Division of Plastic and Reconstructive Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD 21201, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ilias","family":"Iliadis","sequence":"additional","affiliation":[{"name":"Medical School, University of Ioannina, 45110 Ioannina, Greece"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Raymond A.","family":"Pensy","sequence":"additional","affiliation":[{"name":"Division of Plastic and Reconstructive Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD 21201, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0099-2041","authenticated-orcid":false,"given":"Gregory A.","family":"Lamaris","sequence":"additional","affiliation":[{"name":"Division of Plastic and Reconstructive Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD 21201, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,6,12]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"287e","DOI":"10.1097\/PRS.0000000000002860","article-title":"Evidence-based medicine: Management of acute lower extremity trauma","volume":"139","author":"Lachica","year":"2017","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1924","DOI":"10.1056\/NEJMoa012604","article-title":"An analysis of outcomes of reconstruction or amputation after leg-threatening injuries","volume":"347","author":"Bosse","year":"2002","journal-title":"N. Engl. J. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"575","DOI":"10.5999\/aps.2013.40.5.575","article-title":"Reconstruction of the lower extremity using free flaps","volume":"40","author":"Kang","year":"2013","journal-title":"Arch. Plast. Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"66","DOI":"10.1016\/j.jamcollsurg.2009.09.040","article-title":"Lower extremity arterial injury patterns and reconstructive outcomes in patients with severe lower extremity trauma: A 26-year review","volume":"210","author":"Haddock","year":"2010","journal-title":"J. Am. Coll. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"215S","DOI":"10.1097\/PRS.0b013e3182006962","article-title":"The respective roles of plastic and orthopedic surgery in limb salvage","volume":"127","author":"Lerman","year":"2011","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1503","DOI":"10.1097\/00006534-199406000-00027","article-title":"From the reconstructive ladder to the reconstructive elevator","volume":"93","author":"Gottlieb","year":"1994","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1097\/BOT.0b013e31802cbc43","article-title":"Complex limb salvage or early amputation for severe lower-limb injury: A meta-analysis of observational studies","volume":"21","author":"Busse","year":"2007","journal-title":"J. Orthop. Trauma"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"511","DOI":"10.1002\/micr.30020","article-title":"Free flaps for reconstruction of soft tissue defects in lower extremity: A meta-analysis on microsurgical outcome and safety","volume":"36","author":"Xiong","year":"2016","journal-title":"Microsurgery"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"228S","DOI":"10.1097\/PRS.0b013e3182008e12","article-title":"Role of microsurgery in lower extremity reconstruction","volume":"127","author":"Engel","year":"2011","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"582","DOI":"10.1097\/PRS.0b013e3181c82ed1","article-title":"Lower limb salvage in trauma","volume":"125","author":"Ong","year":"2010","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"392","DOI":"10.1055\/s-0043-1776734","article-title":"Surface to perforator index: Assessing the importance of the number of perforators in successful harvesting of the anterolateral thigh flap","volume":"40","author":"Saad","year":"2024","journal-title":"J. Reconstr. Microsurg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"S32","DOI":"10.1016\/j.injury.2019.10.045","article-title":"Selecting a free flap for soft tissue coverage in lower extremity reconstruction","volume":"50","author":"Kozusko","year":"2019","journal-title":"Injury"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1097\/PRS.0000000000003927","article-title":"Muscle versus fasciocutaneous free flaps in lower extremity traumatic reconstruction: A multicenter outcomes analysis","volume":"141","author":"Cho","year":"2018","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"192","DOI":"10.1016\/j.bjps.2025.01.003","article-title":"Letter comments on \u201cadvanced reconstructive techniques following orbital exenteration: The role of LCFA free flaps.\u201d temporalis muscle flap: A simple yet reliable alternative for orbital exenteration reconstruction","volume":"101","author":"Karamitros","year":"2025","journal-title":"J. Plast. Reconstr. Aesthet. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"481","DOI":"10.1615\/JLongTermEffMedImplants.v14.i6.50","article-title":"An organized approach to trauma care: Legacy of R adams cowley","volume":"14","author":"Edlich","year":"2004","journal-title":"J. Long-Term. Eff. Med. Implants"},{"key":"ref_16","first-page":"63","article-title":"Free flap steal syndrome and the loss of free lymphatic tissue flap transplantation in lymphoedema surgery: A case report","volume":"18","author":"Rusli","year":"2023","journal-title":"J. Lymphoedema"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1186\/2046-4053-1-2","article-title":"The nuts and bolts of prospero: An international prospective register of systematic reviews","volume":"1","author":"Booth","year":"2012","journal-title":"Syst. Rev."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: An updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Deeks, J.J., Bossuyt, P.M., Leeflang, M.M., and Takwoingi, Y. (2023). Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy, John Wiley & Sons.","DOI":"10.1002\/9781119756194"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"60","DOI":"10.1136\/bmjebm-2017-110853","article-title":"Methodological quality and synthesis of case series and case reports","volume":"23","author":"Murad","year":"2018","journal-title":"BMJ Evid.-Based Med."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"311","DOI":"10.1097\/PRS.0b013e3182195826","article-title":"The level of evidence pyra- mid: Indicating levels of evidence in plastic and reconstructive surgery articles","volume":"128","author":"Sullivan","year":"2011","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"336","DOI":"10.1097\/00000637-199503000-00020","article-title":"Microvascular steal phenomenon in lower extremity reconstruction","volume":"34","author":"Sonntag","year":"1995","journal-title":"Ann. Plast. Surg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"311","DOI":"10.1007\/BF00178550","article-title":"Free flap \u201csteal\u201d hastening amputation of a revascularized lower limb","volume":"18","author":"Musser","year":"1995","journal-title":"Eur. J. Plast. Surg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"543","DOI":"10.1055\/s-2004-815641","article-title":"Microsurgical management of the diabetic foot","volume":"19","author":"Rainer","year":"2003","journal-title":"J. Reconstr. Microsurg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"II3","DOI":"10.1177\/15266028060130S204","article-title":"Epidemiology and pathophysiology of lower extremity peripheral arterial disease","volume":"13","author":"Garcia","year":"2006","journal-title":"J. Endovasc. Ther."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"64","DOI":"10.1126\/science.1214319","article-title":"Ohm\u2019s law survives to the atomic scale","volume":"335","author":"Weber","year":"2012","journal-title":"Science"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1146\/annurev.fl.25.010193.000245","article-title":"The history of poiseuille\u2019s law","volume":"25","author":"Sutera","year":"1993","journal-title":"Annu. Rev. Fluid Mech."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"110","DOI":"10.1007\/BF02693810","article-title":"The hemodynamics of vein grafts: Measurement and meaning","volume":"15","author":"Skelly","year":"2001","journal-title":"Ann. Vasc. Surg."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"5009","DOI":"10.1016\/j.biomaterials.2007.07.017","article-title":"Prosthetic vascular grafts: Wrong models, wrong questions and no healing","volume":"28","author":"Zilla","year":"2007","journal-title":"Biomaterials"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"355","DOI":"10.1055\/s-0029-1215522","article-title":"Hemodynamic differences in blood flow between free skin and muscles flaps: Prospective study","volume":"25","author":"Nasir","year":"2009","journal-title":"J. Reconstr. Microsurg."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"2495","DOI":"10.1016\/j.bjps.2021.03.022","article-title":"Blood flow distribution after end-to-side anastomosis with wide arteriotomy in extremity free flap surgery","volume":"74","author":"Motomiya","year":"2021","journal-title":"J. Plast. Reconstr. Aesthet. Surg."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"164","DOI":"10.1097\/SAP.0b013e3181e57cb3","article-title":"Flow-through free latissimus dorsi flap for reconstruction of injured limbs: Evaluation of hemodynamic effects on extremity circulation","volume":"65","author":"Nasir","year":"2010","journal-title":"Ann. Plast. Surg."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Nissen, T., and Wynn, R. (2014). The clinical case report: A review of its merits and limitations. BMC Res. Notes, 7.","DOI":"10.1186\/1756-0500-7-264"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"34","DOI":"10.1016\/j.bjps.2024.11.013","article-title":"Enhancing the QUINTET study: Exploring quality of life after open lower limb trauma while strengthening research methodology","volume":"100","author":"Karamitros","year":"2025","journal-title":"J. Plast. Reconstr. Aesthet. Surg."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"145","DOI":"10.1016\/j.jss.2025.03.043","article-title":"Associations in medical research can be misleading: A clinician\u2019s guide to causal inference","volume":"310","author":"Karamitros","year":"2025","journal-title":"J. Surg. Res."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1016\/j.bjps.2024.01.028","article-title":"US air pollution and increased incidence of non-syndromic cleft lip\/palate: Association does not imply causality","volume":"90","author":"Karamitros","year":"2024","journal-title":"J. Plast. Reconstr. Aesthet. Surg."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"233","DOI":"10.1007\/BF00489201","article-title":"Causality in medicine: Towards a theory and terminology","volume":"13","author":"Rizzi","year":"1992","journal-title":"Theor. Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"190","DOI":"10.1016\/j.bjps.2025.01.008","article-title":"Letter comments on: Prevalence of body dysmorphic disorder in plastic surgery: Addressing biases and improving screening approaches","volume":"101","author":"Karamitros","year":"2025","journal-title":"J. Plast. Reconstr. Aesthet. Surg."},{"key":"ref_39","first-page":"1","article-title":"Assessing methodological quality","volume":"Volume 1","author":"Reitsma","year":"2009","journal-title":"Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy Version"},{"key":"ref_40","first-page":"733","article-title":"Reevaluating the impact of scars on satisfaction and HR-QoLafter DIEP-flap breast reconstruction: Methodological concerns and future directions","volume":"49","author":"Karamitros","year":"2024","journal-title":"Aesthet. Plast. Surg."}],"container-title":["Bioengineering"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2306-5354\/12\/6\/647\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T17:50:46Z","timestamp":1760032246000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2306-5354\/12\/6\/647"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6,12]]},"references-count":40,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2025,6]]}},"alternative-id":["bioengineering12060647"],"URL":"https:\/\/doi.org\/10.3390\/bioengineering12060647","relation":{},"ISSN":["2306-5354"],"issn-type":[{"value":"2306-5354","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,6,12]]}}}