scholarly journals Recipient Vessel Thrombectomy and Anastomosis within the Zone of Injury in Microvascular Extremity Reconstruction

2020 ◽  
Vol 05 (01) ◽  
pp. e15-e21
Author(s):  
Jeremy M. Powers ◽  
Jaime H. Choi ◽  
Santosh S. Kale
Keyword(s):  
Success Rate ◽  
Vein Graft ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Senior Author ◽  
Fogarty Catheter ◽  
Vein Grafts ◽  
Recipient Vessel ◽  
Flap Loss ◽  
Extremity Reconstruction

Abstract Background In traumatic extremity reconstruction, it is preferable to perform microvascular anastomoses outside the zone of injury. Alternatively, a recipient-vessel thrombectomy can be performed to improve the arterial inflow, potentially avoiding further proximal dissection and the use of a vein graft. The objective of this study was to evaluate the outcomes of microvascular anastomosis after thrombectomy in the zone of injury. Methods A retrospective review of patients who underwent free tissue transfer for traumatic extremity reconstruction by the senior author from 2013 to 2017 was conducted. Patient demographic and clinical data were gathered as well as use of vein grafts, recipient-vessel thrombectomy, postoperative anticoagulation, and flap outcomes. Results A total of 23 patients underwent 24 free flap procedures for traumatic extremity reconstruction. Ten patients underwent recipient-vessel thrombectomy with 2-Fr Fogarty catheter and were placed on postoperative anticoagulation. In this group overall, there was one case of flap loss due to late wound infection resulting in a 90% success rate. A total of 13 patients underwent 14 free flaps without the use of thrombectomy and vein grafts were performed for 3/14 (21%) patients. In this group, there were four cases of flap loss, resulting in a 71% overall success rate. Conclusion In traumatic extremity reconstruction, if the artery appears to be visibly appropriate with weak inflow, one may consider attempting thrombectomy to restore pulsatile flow prior to harvesting a vein graft. This study suggests this may be effective and safe with no anastomosis-related flap loss in the thrombectomy group. Further research is required to confirm our results.

Geometric Three-Dimensional End-to-Side Microvascular Anastomosis: A Simple and Reproducible Technique

2017 ◽  
Vol 34 (04) ◽  
pp. 258-263 ◽  
Author(s):  
Adrian Ooi ◽  
Daniel Butz ◽  
Sean Fisher ◽  
Zachary Collier ◽  
Lawrence Gottlieb
Keyword(s):  
Three Dimensional ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Suture Line ◽  
Success Rates ◽  
Recipient Vessel ◽  
Wide Range ◽  
Extremity Reconstruction ◽  
Geometric Technique ◽  
The Ideal

Background End-to-side (ETS) anastomoses are useful when preservation of distal vascularity is critical. The ideal ETS microanastomosis should maintain a wide aperture and have a smooth take-off point to minimize turbulence, vessel spasm, and thrombogenicity of the suture line. We have developed a unique, dependable, and reproducible geometric technique for ETS anastomoses, and analyze its efficacy in our series of patients. Methods The geometric ETS technique involves creating a three-dimensional (3D) diamond-shaped defect on the recipient vessel wall, followed by a slit incision of the donor vessel to create a “spatula” fitting this defect. This technique removes sutures from the point of most turbulent blood flow while holding the recipient vessel open with a patch vesselplasty effect. We perform a retrospective review of a single surgeon's experience using this technique. Results The geometric 3D ETS technique was used in 87 free flaps with a total of 102 ETS anastomoses in a wide range of cases including head and neck, trunk and genitourinary, and extremity reconstruction. Overall, free flap success rates were 98%. Conclusions The geometric 3D ETS technique creates a wide anastomosis, minimizes turbulence-inducing thrombogenicity, and mechanically holds the recipient vessel open. It is reliable and reproducible, and when performed properly has been shown to have high rates of success in a large group of free tissue transfer patients.

Proximal versus Distal Recipient Vessels in Lower Extremity Reconstruction: A Retrospective Series and Systematic Review

2018 ◽  
Vol 34 (05) ◽  
pp. 334-340 ◽  
Author(s):  
Zachary Borab ◽  
William Rifkin ◽  
Adam Jacoby ◽  
Z-Hye Lee ◽  
Lavinia Anzai ◽  
...  
Keyword(s):  
Systematic Review ◽  
Lower Extremity ◽  
Free Flaps ◽  
Pooled Analysis ◽  
Perioperative Outcomes ◽  
Complication Rates ◽  
Recipient Vessel ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction ◽  
The Impact

Background Recipient vessels proximal to the zone of injury have traditionally been preferred for lower extremity reconstruction. However, more recent data have shown mixed outcomes when performing anastomoses distal to the zone of injury. We investigated the impact of recipient vessel location on free flap outcomes. Methods Retrospective review (1979–2016); 312 soft tissue free flaps for open tibia fractures met inclusion criteria. Flap characteristics and perioperative outcomes were examined. Systematic review identified articles evaluating anastomosis location and flap outcomes; pooled data analysis was performed. Results More anastomoses were performed proximal to the zone of injury (80.7%) than distal (19.3%). Distal anastomoses were not associated with increased take back rates (19.6%) compared with proximal (23.8%) anastomoses (p = 0.356). Regression analysis comparing proximal and distal anastomoses found no difference in partial flap failures (7.4% vs 11.9%; p = 0.978) or total flap failures (9.3% vs 9.3%; p = 0.815) when controlling for the presence of arterial injury, flap type, and time from injury to coverage. Systematic review yielded 11 articles with 1,245 proximal and 127 distal anastomoses for comparison. Pooled analysis (p = 0.58) and weighted comparative analysis (p = 0.39) found no difference in flap failure rates between proximal and distal groups. Conclusion Our results are congruent with the current lower extremity literature and demonstrate no difference in perioperative complication rates between anastomoses performed proximal or distal to the zone of injury. These findings suggest that anastomotic location choice should be based primarily on recipient vessel quality/flow and ease of access/exposure rather than orientation relative to the zone of injury.

scholarly journals Double free-flap for a bimalleolar defect of lower leg and ankle

2016 ◽  
Vol 49 (01) ◽  
pp. 95-98
Author(s):  
Naren Shetty ◽  
Narendra S. Mashalkar ◽  
Sunder Raj Ellur ◽  
Karishma Kagodu
Keyword(s):  
Donor Site ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Lower Leg ◽  
Donor Site Morbidity ◽  
The Other ◽  
Limb Ischaemia ◽  
Distal Limb ◽  
Limb Defects ◽  
Recipient Vessel

ABSTRACTDouble free-flaps are necessary when tissue cover cannot be sufficed with a single flap. The other factors to be considered when using two free flaps for resurfacing of distal limb defects are the availability of more than one recipient vessel, the risk of distal limb ischaemia and the donor site morbidity of double flap harvest. If these factors are adequately addressed, double free-flaps can be safely executed for resurfacing distal limb defects with minimal morbidity. We report the simultaneous harvest and transfer of the anterolateral and anteromedial thigh flaps inset and vascularised as double free-flaps to resurface a large bimalleolar defect in a 14-year-old boy with no additional morbidity as compared to that of a single free tissue transfer.

Importance of Vascularity and Selecting the Recipient Vessels of Lower Extremity Reconstruction

2020 ◽  
Author(s):  
Joon Pio Hong ◽  
Changsik John Park ◽  
Hyunsuk Peter Suh
Keyword(s):  
Decision Making ◽  
Lower Extremity ◽  
Free Flaps ◽  
Recipient Vessel ◽  
Multiple Factors ◽  
Surrounding Environment ◽  
The Status ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction

Abstract Background Successful lower extremity reconstruction using free flaps begins by identifying a good recipient vessel and understanding the surrounding environment of the defect. Methods One should consider multiple factors when selecting the recipient vessel such as the status of the axial arteries, trying to preserve flow as much as possible, extent and severity of the defect, and ultimately what type of anastomosis will be ideal. Results Multiple factors of importance are reviewed and show the relevance in decision making and provide an algorithm. Conclusion In addition to the multiple factors to be considered, the ultimate decision should be made on the table during surgery when the actual artery or vein is exposed and shows signs of good pulsation and flow.

scholarly journals Bilateral Breast Reconstruction with Abdominal Free Flaps: A Single Centre, Single Surgeon Retrospective Review of 55 Consecutive Patients

2016 ◽  
Vol 2016 ◽  
pp. 1-9 ◽  
Author(s):  
Peter McAllister ◽  
Isabel Teo ◽  
Kuen Chin ◽  
Boikanyo Makubate ◽  
David Alexander Munnoch
Keyword(s):  
Breast Reconstruction ◽  
Failure Rate ◽  
Retrospective Review ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Senior Author ◽  
Complication Rates ◽  
Immediate Reconstruction ◽  
Flap Failure ◽  
Increased Risk

Breast reconstruction using free tissue transfer is an increasingly utilised oncoplastic procedure. The aim was to review all bilateral breast reconstructions using abdominal free flaps by a single surgeon over an 11-year period (2003–2014). A retrospective review was performed on all patients who underwent bilateral breast reconstruction using abdominal free flaps between 2003 and 2014 by the senior author (DAM). Data analysed included patient demographics, indication for reconstruction, surgical details, and complications. Fifty-five female patients (mean 48.6 years [24–71 years]) had bilateral breast reconstruction. The majority (41, 74.5%) underwent immediate reconstruction and DIEP flaps were utilised on 41 (74.5%) occasions. Major surgical complications occurred in 6 (10.9%) patients, all of which were postoperative vascular compromise of the flap. Failure to salvage the reconstruction occurred on 3 (5.5%) occasions resulting in a total flap failure rate of 2.7%. Obesity (>30 kg/m2) and age > 60 years were shown to have a statistically increased risk of developing postoperative complications (P<0.05). Our experience demonstrates that abdominal free flaps for bilateral breast reconstruction fares well, with a flap failure rate of 2.7%. Increased body mass index and patient age (>60 years) were associated with higher complication rates.

scholarly journals Creation of Superficial Temporal Arteriovenous Loop for Staged Free Tissue Transfer for Dural Coverage in the Setting of Radiation: A Case Report

2020 ◽  
Vol 5 ◽  
pp. 247275122097809
Author(s):  
Pallavi A. Kumbla ◽  
René P. Myers
Keyword(s):  
Head And Neck ◽  
Free Tissue Transfer ◽  
Elderly Male ◽  
Large Defect ◽  
Vein Grafts ◽  
Recipient Vessel ◽  
Tissue Transfer ◽  
Increased Risk ◽  
Arteriovenous Loop ◽  
Superficial Temporal Vessels

Free tissue transfer for dural coverage can be challenging for various reasons. In the case of malignancy, patients often have received significant doses of radiation to the head and neck leading to fibrosis and osteoradionecrosis. Not only will free tissue transfer need to accommodate an often large defect but will need to protect intracranial contents. Recipient vessel quality and patency is often affected by comorbidities such as diabetes mellitus and coronary artery disease and can be compounded by radiation. Due to these factors, more proximal vessels in the head and neck are often pursued but due to insufficient length, often require vein grafts or arteriovenous loops to reach the donor vessels for anastomosis. This requires larger incisions and harvesting of lengthy veins. In this study, we discuss a technique of harvesting a small dorsal hand vein, that is hidden well in a hand crease, to create an arteriovenous loop between the superficial temporal vessels. Benefits include exploration of the recipient superficial temporal vessels prior to craniectomy without creating additional incisions, readily accessible recipient vessels to reach donor vessels without harvesting lengthy vein grafts, and allowing for arterialization of the superficial temporal vein leading to decreased venous congestion and thrombosis. While this can be done in 1 stage, we perform this in 2 stages to avoid an increased number of anastomoses and increased risk of flap failure. We present the case of an elderly male with multiple comorbidities and scalp osteoradionecrosis secondary to malignancy who this technique was successfully performed on.

Vein Grafting in Microsurgical Lower Extremity Reconstruction: Outcome Analysis of Primary versus Secondary Salvage Procedures

2021 ◽  
Author(s):  
Emre Gazyakan ◽  
Lingyun Xiong ◽  
Jiaming Sun ◽  
Ulrich Kneser ◽  
Christoph Hirche
Keyword(s):  
Lower Extremity ◽  
Free Flap ◽  
Free Flaps ◽  
Matched Pair ◽  
Complication Rates ◽  
Matched Pair Analysis ◽  
Flap Loss ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction ◽  
Pair Analysis

Abstract Objective Many microsurgeons fear high complication rates and free flap loss when vein grafting is necessary to restore blood flow at the recipient site. The aims of this study were to comparatively analyze surgical outcomes of interposition vein grafts (VG) in microsurgical primary lower extremity reconstruction and secondary salvage procedures. Patients and Methods A retrospective study was conducted on 58 patients undergoing free flap transfers with vein grafting for primary lower extremity reconstruction (cohort 1) and secondary salvage procedures (cohort 2) between 2002 and 2016. A matched-pair analysis of both cohorts and 58 non-VG flaps was performed. Patient data, preoperative conditions, flap and vein graft characteristics, postoperative outcomes such as flap failure, thrombosis, and wound complications were analyzed. Results A total of 726 free flap transfers were performed. In total, 36 primary reconstructions (5%) utilized 41 interposition VG (cohort 1). Postoperative vascular compromise was observed in 65 free flaps (9%). In total, 22 out of 65 secondary salvage procedures (33.8%) utilized 26 interposition VG (cohort 2). Two total flap losses occurred in each cohort (5.6 vs. 9.1%; p = 0.63). Postoperative complications were observed in 38.9% of free flaps in cohort 1 and 72.7% in cohort 2 (p = 0.01). Takeback for microvascular compromise was comparable in both cohorts (19.4 vs. 22.7%; p = 0.75). Microvascular complications occurred more often in cohort 2 (22.7%) than in cohort 1 (8.3%; p = 0.28). Lower extremity salvage rates were high among both cohorts (94.4 vs. 90.9%; p = 0.63). Matched-pair analysis did not show any relevant differences on takebacks and flap loss (p = 0.32 and p = 1.0). Conclusion In complex lower extremity reconstructions, VG can be performed with acceptable complication rates and outcomes in primary and especially in salvage cases. With careful planning and a consistent surgical protocol, VG can provide reliable success rates in limb salvage.

scholarly journals Pedicle streaking: A novel and simple aid in pedicle positioning in free tissue transfer

2015 ◽  
Vol 48 (03) ◽  
pp. 274-277 ◽  
Author(s):  
Aditya Aggarwal ◽  
Hardeep Singh ◽  
Sanjay Mahendru ◽  
Vimalendu Brajesh ◽  
Sukhdeep Singh ◽  
...  
Keyword(s):  
Methylene Blue ◽  
Success Rate ◽  
Single Case ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Blue Dye ◽  
Methylene Blue Dye ◽  
Safe Method ◽  
Tissue Transfer ◽  
Novel Method

ABSTRACT Introduction: The pedicle positioning in free tissue transfer is critical to its success. Long thin pedicles are especially prone to this complication where even a slight twist in the perforator can result in flap loss. Pedicles passing through the long tunnels are similarly at risk. Streaking the pedicle with methylene blue is a simple and safe method which increases the safety of free tissue transfer. Materials and Methods: Once the flap is islanded on the pedicle and the vascularity of the flap is confirmed, the pedicle is streaked with methylene blue dye at a distance of 6-7 mm. The streaking starts from the origin of the vessels and continued distally on to the under surface of flap to mark the complete course of the pedicle in alignment. The presence of streaking in some parts and not in rest indicates twist in the pedicle. Observation and Results: Four hundred and sixty five free flaps have been done at our centre in the last 5 years. The overall success rate of free flaps is 95.3% (22 free flap failures). There has not been a single case of pedicle twist leading to flap congestion and failure. Conclusion: This simple and novel method is very reliable for pedicle positioning avoiding any twist necessary for successful free tissue transfer.

scholarly journals Tunneling Technique for Expedited Fibula Free Tissue Harvest

2013 ◽  
Vol 6 (4) ◽  
pp. 233-236
Author(s):  
Yadranko Ducic ◽  
Robert DeFatta ◽  
Erik M. Wolfswinkel ◽  
William M. Weathers ◽  
Larry H. Hollier
Keyword(s):  
Retrospective Chart Review ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Harvest Time ◽  
Tourniquet Time ◽  
Flap Loss ◽  
Free Fibula ◽  
Free Tissue Transfer Flap ◽  
Ankle Function ◽  
Oromandibular Reconstruction

Free fibula transfer can be associated with a slow and tedious dissection/harvest due to difficulty in visualizing the deeper structures. The purpose of this article is to review the first author's (Y.D.) experience with a novel technique for expedited harvest of fibula free flaps for mandibular reconstruction. A retrospective chart review was performed using the first author's clinical practice using chart data from September 1997 to August of 2007. All patients with available chart data who had undergone free fibular transfer for oromandibular reconstruction were included in this study. Charts that met the specified inclusion criteria were reviewed for patient demographic information, reason for free tissue transfer, flap loss rates (partial and total) and reasons for flap loss, average fibula harvest time (tourniquet time), and foot and ankle function postoperatively. During this time, a total of 283 fibula free flaps were performed in 276 patients. The average fibula harvest time (tourniquet time) for all cases was 22.6 minutes, with a range of 14 to 29 minutes. A total of 13 flaps were unsuccessful (failure rate of 4.6%, with 5 total and 8 partial flap losses). This newly described technique will allow for expedited and simplified harvest of fibula free flaps.

scholarly journals Free tissue transfer for trophic ulcer complicating leprosy

2009 ◽  
Vol 42 (01) ◽  
pp. 115-117
Author(s):  
Yogesh C. Bhatt ◽  
Nikhil S. Panse ◽  
Kinnari A. Vyas ◽  
Gunjan A. Patel
Keyword(s):  
Treatment Options ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Local Flaps ◽  
Foot Care ◽  
Recipient Vessel ◽  
Bone Removal ◽  
Anterior Tibial ◽  
Leprosy Patients ◽  
Arterial Anastomosis

ABSTRACTPlantar ulceration is the commonest disability in leprosy and occurs in about 10 to 20% of leprosy patients. Various loco-regional flaps have been described for reconstruction of trophic ulcers; however, very large defects are not amenable to local flaps and free flaps form one of the important treatment options. We present a case of a post Hansen's trophic ulcer over the forefoot managed using a radial artery forearm free flap. Debridement of the osteomyelitic bone, removal of the bony prominences, coverage by a well-vascularised tissue, end-to-side arterial anastomosis, use of anterior tibial as the recipient vessel and good postoperative compliance in foot care on the part of the patient gave us good results.

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