Abstract
The field of reconstructive microsurgery is experiencing tremendous growth, as evidenced by recent advances in face and hand transplantation, lower limb salvage after trauma, and breast reconstruction. Common to all of these procedures is the creation of a nutrient vascular supply by microsurgical anastomosis between a single artery and vein. Complications related to occluded arterial inflow and obstructed venous outflow are not uncommon, and can result in irreversible tissue injury, necrosis, and flap loss. At times, these complications are challenging to clinically determine. Since early intervention with return to the operating room to re-establish arterial inflow or venous outflow is key to flap salvage, the accurate diagnosis of early stage complications is essential. To date, there are no biochemical markers or serum assays that can predict these complications. In this study, we utilized a rat model of flap ischemia in order to identify the transcriptional signatures of venous congestion and arterial ischemia. We found that the critical ischemia time for the superficial inferior epigastric fasciocutaneus flap was four hours and therefore performed detailed analyses at this time point. Histolgical analysis confirmed significant differences between arterial and venous ischemia. The transcriptome of ischemic, congested, and control flap tissues was deciphered by performing Affymetrix microarray analysis and verified by qRT-PCR. Principal component analysis revealed that arterial ischemia and venous congestion were characterized by distinct transcriptomes. Arterial ischemia and venous congestion was characterized by 408 and 1536>2-fold differentially expressed genes, respectively. qRT-PCR was used to identify five candidate genes Prol1, Muc1, Fcnb, Il1b, and Vcsa1 to serve as biomarkers for flap failure in both arterial ischemia and venous congestion. Our data suggests that Prol1 and Vcsa1 may be specific indicators of venous congestion and allow clinicians to both diagnose and successfully treat microvascular complications before irreversible tissue damage and flap loss occurs.
Highlights
The duration of ischemia that results in irreversible damage to the flap defines the time from which to assess the sequential molecular events that lead to flap necrosis
Flaps after 4 hours of venous congestion showed reduced survival compared to arterial ischemia, the difference did not reach statistical significance (P = 0.292)
Global Transcriptome Profiles in Ischemic Flaps Because 4 hours of ischemia in flaps show a substantial difference in survival rate, we proposed that this characteristic pathology is accompanied with changes in global gene expression
Summary
Advances in reconstructive microsurgery have created a paradigm shift in the restoration of form and function, allowing for the dynamic repair of devastating injuries, severely diseased tissue, and previously unreconstructible wounds [1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18]. Composite tissue allotransplantation of the face and upper extremity is a reality, with over seventy procedures performed to date and an increasing amount of clinical centers offering these operations to their patients. Surgical complications related to occluded arterial inflow and obstructed venous outflow can result in irreversible injury to tissues and may result in tissue compromise and necrosis
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