Use of a bovine pericardial patch angioplasty for completion of a complicated end to side anastomosis of a recipient vessel in the free flap reconstruction of a radiated wound: A case report.

Abstract

Soft tissue sarcomas treated by extensive surgical resection and adjuvant radiation can lead to large tissue deficits that require free flap repair. Significant radiation can further compromise vessels necessitating novel therapeutic approaches. We describe an 82-year-old man who presented with a posterior thigh sarcoma and underwent wide local tumor resection and immediate reconstruction with a microvascular free flap. Due to radiated recipient vessels, this case required bovine patch angioplasty as a conduit for end to side anastomosis. Initial resection and pathology revealed a large myxofibrosarcoma. Wide local resection and radiotherapy resulted in a large irradiated soft tissue defect of 26 x 15 x4cm with exposed, radiation damaged neurovascular structures, and a lack of available regional flap options. The planned free flap, a 30 x8cm skin island from the left latissimus dorsi muscle with end-to-side anastomosis to the popliteal artery was complicated by friability of the vessel wall and insufficient perfusion. Given the extent of resection and radiation, there were no alternative recipient vessels present within the field. A bovine pericardial patch angioplasty of 2.5cm in length was performed to the diseased popliteal vessel and an end to side anastomosis was successfully performed between the thoracodorsal artery and the patch. Improved reperfusion of the free flap was noted immediately following anastomosis indicating completion of the anastomosis of our complicated recipient vessel. During the uncomplicated postoperative course, the flap had good perfusion with Doppler signals present, and incision sites intact at discharge from acute hospitalization. Recurrent sarcomas that have undergone extensive resection and radiotherapy pose significant reconstructive challenges. For defects that require free tissue reconstruction when there are limited options for healthy, recipient vessels, bovine pericardial patch angioplasty may act as a robust conduit for diseased vessels.