Recipient Artery Research Articles

Microvascular Free Flap Reconstruction of Thigh Defects After Tumor Resection in the Setting of Radiation.

Soft tissue reconstruction of the thigh defects can usually be achieved with local options. Free tissue transfer may be indicated in very large defects with exposed vital structures and/or a history of radiation therapy where the healing potential of local option is poor. In this study, we evaluated our experience on microsurgical reconstruction of oncological and irradiated thigh defects to assess the risk factors for complications. Institutional review board-approved retrospective case series study using electronic medical records from 1997 to 2020 was conducted. All patients with irradiated thigh defects derived from oncological resections who underwent microsurgical reconstruction were included. Patient demographics and clinical and surgical characteristics were recorded. Twenty free flaps were transferred in 20 patients. Mean age was 60 ± 11.8 years, and median follow-up time was 24.3 months (interquartile range [IQR], 71.4-9.2 months). The most common type of cancer was liposarcoma (n = 5). Neoadjuvant radiation therapy was performed in 60%. Most commonly used free flaps were latissimus dorsi muscle/musculocutaneous flap (n = 7) and anterolateral thigh flap (n = 7) Nine flaps were transferred immediately after resection. Overall, 70% of arterial anastomoses were end-to-end, whereas 30% were end-to-side. Deep femoral artery branches were chosen as the recipient artery in the 45%. Median length of hospital stay was 11 days (IQR, 16.0-8.3 days), and median time to start weight-bearing was 20 days (IQR, 49.0-9.5 days). All were successful except for 1 patient who required additional pedicled flap coverage. The overall major-complication rate was 25% (n = 5, hematoma = 2, venous congestion requiring emergent exploration surgery = 1, wound dehiscence = 1, surgical site infection = 1). Cancer recurred in 3 patients. One required amputation due to cancer recurrence. Age (hazard ratio [HR], 1.14; P = 0.0163), tumor volume (HR, 18.8; P = 0.0006), and resection volume (HR, 2.24; P = 0.0019) were statistically significantly associated with having a major complication. Based on the data, microvascular reconstruction of irradiated post-oncological resection defects shows high flap survival rate and success. Given the large size of flap required, the complex nature and size of these wounds, and history of radiation, wound healing complications are common. Despite this, free flap reconstruction should be considered in irradiated thighs with large defects. Studies with larger cohort and longer follow-up are still required.

Analysis of Risk Factors for Epilepsy after Combined Re-Vascularization in Adult Patients with Moyamoya Disease.

Re-vascularization is an effective treatment for moyamoya disease (MMD) patients, including direct re-vascularization, indirect re-vascularization and combined re-vascularization, in which combined re-vascularization is particularly widely used. At present, there are few reports on the analysis of epilepsy after combined re-vascularization surgery. To analysis the risk factors of epilepsy in adult MMD patients after combined re-vascularization. Patients with MMD who underwent combined re-vascularization in the Department of Neurosurgery of the First People's Hospital of Yunnan Province from January 2015 to June 2020 were included. Their pre-operative and post-operative complication-related indicators were collected. Finally, logistic regression was used to analyze the clinical risk factors of epilepsy in MMD patients after operation. The incidence of epilepsy after combined re-vascularization was 15.5%. Univariate analysis showed that pre-operative ischemic or hemorrhagic stroke, pre-operative epilepsy, pre-operative history of diabetes, the location of the bypass recipient artery (frontal or temporal lobe), post-operative new cerebral infarction, hyper-perfusion syndrome, and post-operative intra-cranial hemorrhage were the clinical risk factors of epilepsy in MMD patients (all P < 0.05). Multi-variate logistic regression analysis showed that pre-operative epilepsy, the location of the bypass recipient artery, new cerebral infarction, hyper-perfusion syndrome, and post-operative intra-cranial hemorrhage (all P < 0.05) were independent risk factors for post-operative epilepsy in MMD patients. Pre-operative epilepsy, the location of the bypass recipient artery, new cerebral infarction, hyper-perfusion syndrome, and intra-cranial hemorrhage may have a causal relationship with epilepsy in adult MMD patients. It is suggested that some risk factors could be intervened to reduce the incidence of post-operative epilepsy in MMD patients.

Is STA really a low-flow graft? A quantitative ultrasonographic study of the flow of STA for cerebral revascularization in MMD patients.

Direct revascularization remains an important tool in the treatment of patients with Moyamoya disease (MMD). The superficial temporal artery (STA) is the most commonly used donor vessel for direct bypass, and an STA graft has traditionally been considered a low-flow graft for flow augmentation. This study aimed to quantitatively evaluate the blood flow of the STA after direct revascularization. All direct revascularization procedures performed between 2018 and 2021 by one experienced neurosurgeon were screened. Quantitative ultrasound was used to measure the flow data of the patient's bilateral parietal branch of the STA(STA-PB), the bilateral frontal branch of the STA(STA-FB), and the left radial artery. Data on the patients' basic information, Suzuki grade, Matsushima type, anastomosis type, and blood biochemical parameters were collected and analyzed using univariate and multivariate models. An MBC Scale scoring system was proposed to evaluate the recipient artery network of the middle cerebral artery (MCA) tree. The relationship between MBC Scale score and STA graft flow was statistically analyzed. In total, 81 patients (43 males and 38 females) successfully underwent STA-MCA bypass and were included in this study. The mean flow rates in the STA-PB graft on 1 day preoperatively, 1 day postoperatively, 7 days postoperatively, and >6 months postoperatively (long-term) were 10.81, 116.74, 118.44, and 56.20 mL/min respectively. Intraoperative graft patency was confirmed in all patients. Comparing the preoperative and all postoperative time points, the STA-PB flow rates were statistically significant (p < 0.001). The MCA-C score was significantly associated with postoperative flow rate on day 1 (p = 0.007). The STA is a useful donor artery for direct revascularization inpatients with MMD and can provide sufficient blood supply to the ischemic cerebral territory.

Large Frontal Defect Reconstructed with a Suprafascial Anterolateral Thigh Flap and Brow Suspension with a Fascia Lata Frontalis Sling

A 60-year-old gentleman presented with a single, dark scaly lesion over the forehead for the past 8 years. It started as a small plaque spontaneously, insidious in onset and gradually progressed to the present size. There was no history of trauma, pain or bleeding from the lesion. No history of similar complaints in the family. On examination, there was a large hyperpigmented plaque measuring 15 x 10 cm with well-defined margins and rolled-out edges with ulceration 2 x 0.5cm at the centre. (Fig. 1) Edge wedge biopsy from the lesion revealed a proliferation of basaloid cells which showed features consistent with basal cell carcinoma - atypical mitosis and peripheral palisading. After obtaining anaesthetic fitness, we proceeded with wide local excision with 1cm margin done by the surgical oncology team. (Fig. 2) We then followed by reconstruction of the frontalis sling using fascia lata and covered the defect with a free suprafascial ALT flap with superficial temporal as the recipient artery as an end-to-end anastomosis. (Fig. 3, 4) The donor site was resurfaced with SSG. The histopathology report was consistent with basal cell carcinoma without any perineural involvement. The early postoperative period showed the flap supple and soft with no oedema. (Fig. 5) On regular follow-up, the flap was well settled with good cosmesis. (Fig. 6)

Vascularized Free Fibular Flap in Oral and Maxillofacial Reconstruction: A 20-year Experience at a Single Institution Using 2640 Flaps.

This retrospective study reviewed all patients who underwent oral and maxillofacial reconstruction with fibular flaps in the last 2 decades at a single hospital. We reviewed all patients with fibular flaps from 1999 to 2018. The following data were collected: sex; age; reconstruction region; diagnosis; the number of days spent in the hospital after surgery; time spent using a tourniquet for harvesting a fibula flap; vessels at the recipient site; the prevalence of unplanned reoperations; the prevalence of flap failure; history of preoperative radiotherapy; virtual surgical planning; segments of the fibula. In total, 2640 patients were included. The mean age was 45.5 years. The most prevalent region of reconstruction was the mandible (n=2347, 88.9%). The most common diagnosis was squamous cell carcinoma (n=1057, 40.0%). The mean number of days spent in the hospital after surgery decreased year-by-year from 18.3 days to 10.4 days. The first choice of recipient artery was the facial artery (n=1643, 62.2%) and that of the recipient vein was the external jugular vein (n=1196, 45.3%). The prevalence of surgical success was 97.6%. Prevalence of unplanned reoperations was 7.5%. The fibular flap was a good choice for oral and maxillofacial bony reconstruction in most cases.

A Heterotopic Mouse Model for Studying Laryngeal Transplantation

Laryngeal heterotopic transplantation, although a technically challenging procedure, offers more scientific analysis and cost benefits compared to other animal models. Although first described by Shipchandler et al. in 2009, this technique is not widely used, possibly due to the difficulties in learning the microsurgical technique and time required to master it. This paper describes the surgical steps in detail, as well as potential pitfalls to avoid, in order to encourage effective use of this technique. In this model, the bilateral carotid arteries of the donor larynx are anastomosed to the recipient carotid artery and external jugular vein, allowing for blood flow through the graft. Blood flow can be confirmed intraoperatively by the visualization of blood filling in the graft bilateral carotid arteries, reddening of the thyroid glands of the graft, and bleeding from micro vessels in the graft. The crucial elements for success include delicate preservation of the graft vessels, making the correct size arteriotomy and venotomy, and using the appropriate number of sutures on the arterial-arterial and arterial-venous anastomoses to secure vessels without leakage and prevent occlusion. Anyone can become proficient in this model with sufficient training and perform the procedure in approximately 3 h. If performed successfully, this model allows for immunologic studies to be performed with ease and at low cost.

Designing a flow-controlled STA-MCA anastomosis based on the Hagen-Poiseuille law for preventing postoperative hyperperfusion in adult moyamoya disease.

Technical improvements for preventing postoperative symptomatic cerebral hyperperfusion (CHP) during superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis for moyamoya disease (MMD) were seldom reported. The aim of this study was to investigate the significance of application of a novel flow-controlled concept which voluntarily reduces the hemodynamic difference between the donor and recipient arteries based on the Hagen-Poiseuille law when performing direct anastomoses of recipient parasylvian cortical arteries (PSCAs) with anterograde hemodynamic sources from the MCA (M-PSCAs) in adult MMD. This was a retrospective observational study. Direct anastomoses of recipient M-PSCAs were performed on 89 symptomatic hemispheres in 82 adult MMD patients in our hospital from January 2020 to June 2021. They were divided into the flow-controlled group (patients who received direct anastomosis under designed flow-controlled principles) and non-flow-controlled group (patients who received conventional direct anastomosis to obtain maximum flow). The patients' basic characteristics and incidence of postoperative CHP were compared between the two groups. Risk factors for occurrence of postoperative CHP were analyzed. Overall, 36 hemispheres were included in the non-flow-controlled group and 53 in flow-controlled group. The incidences of postoperative focal (22.6%) and symptomatic CHP (5.7%) in the flow-controlled group were significantly lower than those (focal, 52.8%; symptomatic, 25.0%) in the non-flow-controlled group (p = 0.003 and 0.009, respectively). Multivariate analysis revealed that the flow-controlled concept was significantly associated with the development of focal (p = 0.005) and symptomatic (p = 0.012) CHP. The flow-controlled STA-MCA anastomosis can significantly decrease the incidence of postoperative CHP during direct anastomoses of recipient M-PSCAs in adult MMD.

Two stages of salvaging an extensively necrotic foot with chronic limb‐threatening ischemia by arterialization of great saphenous vein and free latissimus dorsi musculocutaneous flap transfer for wound coverage with the arterialized vein as the recipient vessel: A case report

Patients with chronic limb-threatening ischemia (CLTI) without other options for adequate arterial revascularization could undergo deep (or distal) venous arterialization for limb salvage. Additionally, patients with extensive foot wound with CLTI sometimes require free flap transfer for limb salvage. We herein report a case of successful reconstructive limb-salvage surgery for an extensively necrotic foot with CLTI, using a two-stage operation involving venous arterialization using foot-perforating veins and subsequent free flap transfer (with preservation of the arterialized vein). The patient was a 59-year-old man with CLTI. The patient's right foot had dry necrotic tissue after Lisfranc joint amputation. Only one straight-line to the posterior tibial artery was achieved after endovascular therapies (four times). At the first stage of surgery, an arterial-venous shunt bypass from the superficial femoral artery to the distal great saphenous vein (GSV) (near the foot-perforating vein) was created. Arterial blood supply reached the necrotic area via the foot venous circulation system. At the second stage of surgery, free latissimus dorsi musculocutaneous flap (8 × 27 cm) transfer with preservation of the arterialized vein was performed. The pedicle artery was anastomosed to the bypass graft (end-to-side). The pedicle vein was anastomosed to the proximal stump of the GSV (end-to-end). The flap and residual foot survived completely, at a one-year follow-up postoperatively. An indocyanine green bypass-through angiography revealed the angiosome through the venous arterialization bypass graft, which included the flap; entire forefoot; and partial regions of the midfoot and heel. This two-stage operation might be considered a useful option for limb-salvage and complete wound-healing in patients with severe non-healing wound with CLTI. The two methods could compensate and overcome the problems of either method: incomplete wound-healing after venous arterialization, and the absence of a recipient artery for free flap transfer.

Use of absorbable hemostat bolster for prevention of donor renal artery kinking in kidney transplant.

Transplant renal artery stenosis due to mechanical kinking is a rare but significant complication in kidney transplantation that can lead to graft dysfunction due to graft hypoperfusion, delayed graft function, or even global kidney infarction. When detected during surgery, re-anastomosis is usually performed after re-clamping, which inevitably prolongs the warm ischemia time, and increases the possibility of primary graft non-function. In this report, we describe a novel, noninvasive surgical technique whereby the donor renal artery is padded with absorbable hemostatic material (i.e., Surgicel) bolster, placed below the middle third of the renal artery in recipients who were found to have mechanical kinking during the implantation procedure. The bolster technique was used in 12 kidney transplant recipients who were found to have kinking of the donor artery during the primary surgery. After pillowing the renal artery with absorbable hemostatic bolster, no residual kinking was observed intra-operatively, and good allograft perfusion was confirmed with no Doppler ultrasound evidence of renal artery stenosis confirmed at 1 week, 1 month, and 1 year after transplantation.

Anterolateral Thigh Flap Coverage for Large Posterior Defects of the Elbow.

This study highlights the advantages and disadvantages of Anterolateral Thigh (ALT) free flap using the brachial artery as the recipient vessel in large posterior defects of the elbow with early mobilization. Eight patients with a soft tissue defect on the posterior elbow underwent reconstruction with an ALT free flap. Average age and follow-up were 29.5years (range, 18-43years) and 54months (range, 35-76months), respectively. All defects were on the posterior side, and brachial arteries on the anterior side were used as the recipient artery in all cases. Four defects were created by tumor excision, four were exposed with hardware after fixation of distal humeral and/or proximal ulna fractures. The dimensions of defects were between 80 and 352cm2. Cases were evaluated according to function (ROM), complications, tissue quality anticipated from reconstruction and immobilization time after the reconstruction. All flaps except one survived and met the tissue quality anticipated from this reconstruction. In the bigger flaps, an apparent ugly scar at the donor site was the main problem. The flap on the posterior, and recipient artery on the anterior had no adverse effects on early motion of the elbow. Two cases with fractures had minimal restriction of elbow movement due to post-traumatic stiff elbow. There was one case of partial flap loss after myocardial infarction. After the patient was medically stable, the remaining distal defect was closed with a pedicled radial forearm flap. ALT free flap has numerous advantages in covering defects at the posterior elbow such as being pliable, thin and durable skin, with a long and reliable pedicle reaching the brachial artery without causing any problem in early motion and surgical reconstruction can be easily completed in the supine position.

EC-IC Bypass: “Learning Curve” Experiences of Initial 100 Bypasses in Bangladesh

Abstract Objectives Extracranial to intracranial (EC-IC) bypass is an important part of the armamentarium of a neurosurgeon in managing different vascular and neoplastic pathologies. Here, we report our initial experiences of EC-IC bypasses as experiences in the ‘learning curve’, including preparation and training of the surgeon, getting cases, patient selection, imaging, operative skills and microtechniques, complications, follow-up, and outcome. Lessons learned from the ‘learning curve experiences’ can be very useful for young vascular neurosurgeons who are going to start EC-IC bypass or have already started to perform and find themselves in the learning curve. Methods From July 2009 to September 2018, 100 EC-IC bypasses were performed. We looked back to these cases of EC-IC bypass as our initial or ‘learning curve’ experiences. The recorded data of patient management (EC-IC bypass patient) were reviewed retrogradely. Our preparation for EC-IC bypass was described briefly. Case selection, indications, preparation of the patient for operation, techniques and technical experiences, preoperative difficulties and challenges, postoperative follow-up, complications, patency status of the bypass, and ultimate results were reviewed and studied. Result A total of 100 bypasses were performed in 83 patients, of which 43 were male and 40 were female. The age range was from 04 to 72 years old (average 32 years old). Eleven patients were lost to follow-up postoperatively after 3 months and they were not even available for telephone follow-up. The follow-up period ranged from 3 to 120 months (average of18.4 months). Eight bypasses were high flow bypasses, whereas the number of low flow STA-MCA bypasses was 92. Indication of bypass were (in 83 cases):1. Arterial stenosis/occlusion/dissection causing cerebral ischemia (middle cerebral artery [MCA] stenosis/occlusion-05, MCA dissection-04, internal carotid artery [ICA] occlusion-19); 2. Intracranial aneurysm-30; 3. Moya-Moya disease-21; and 4. Direct carotid cavernous fistula [CCF]-04. Common clinical presentation was hemiparesis &amp; dysphasia in ischemic group with history of transient ischemic attack (H/O TIA) (including Moya Moya disease). Features of subarachnoid hemorrhage (SAH) were the presenting symptoms in intracranial aneurysm group. The average ischemic time, due to clamping of recipient artery, was 28 minutes (range: 20–60 minutes). There was no clamp-related infarction. Two anastomoses were found thrombosed intraoperatively.One preoperatively ambulant patient deteriorated neurologically in the postoperative period. She developed hemiplegia but improved later. Here, the cause seemed to be hyperperfusion. Headache resolved in all cases. TIA and seizures were also gone postoperatively. Ophthalmoplegia recovered in all cases in which it was present, except in one CCF, in which abducent nerve palsy persisted. Complete unilateral total blindness developed in one patient postoperatively (due to ophthalmic artery occlusion), where high flow bypass with ICA occlusion were performed. Red eye and proptosis were cured in CCF cases. Motor and sensory dysphasia improved in all cases in which it was present, except for one case in which preoperative global aphasia converted to sensory aphasia in the postoperative period. Three patients died in the postoperative period. The rest of the patients improved postoperatively. All patients were ambulant with static neurostatus and without new stroke/TIA until the last follow-up. All bypasses were patent until the last follow-up. Conclusion The initial experiences of 100 cases of EC-IC bypass revealed even in inexperienced hand mortality and morbidity in properly indicated cases were low and result were impressive according to the pathological group and aim of bypass. Lessons learned from these experiences can be very helpful for new and beginner bypass neurosurgeons

Reconstruction of upper extremity soft tissue defects with free flaps

Amaç: Çeşitli etiyolojik nedenler sonucu ortaya çıkabilen üst ekstremite defektlerinin rekonstrüksiyonu için literatürde pek çok yöntem tanımlanmıştır. Bu yöntemler arasında lokal veya bölgesel flepler oldukça sık kullanılmakta olup çoğu defekt başarılı bir şekilde rekonstrükte edilebilmektedir. Bununla birlikte bazı büyük ve kompleks defektlerde, teknik olarak daha zor olan serbest flep seçenekleri&#x0D; kaçınılmaz olabilmektedir. Çalışmamızda serbest fleplerle üst ekstremite rekonstrüksiyonu hakkındaki tecrübelerimizi sunmayı planladık.&#x0D; Gereç ve Yöntem: 2015 - 2021 yılları arasında 9 hastada (3 Kadın, 6 Erkek) serbest fleplerle üst ekstremite rekonstrüksiyonu uygulandı. Hastaların yaşları 22-68 arasında değişmekteydi. Serbest flep tercihlerimiz arasında 4 hastada anterolateral uyluk flebi, 4 hastada latissimus dorsi serbest flebi ve 1 hastada radial ön kol serbest flebi yer almaktaydı. Hastaların defektleri; 3 hastada el dorsumu, 1&#x0D; hastada amputasyon güdüğü, 2 hastada ön kol ile birlikte el dorsumu ve 3 hastada ön kol ile birlikte dirsekte bulunmaktaydı.&#x0D; Bulgular: Bütün hastalarda alıcı arter olarak radial arter seçildi. Alıcı ven olarak, radial arterin konkomitan veni veya yüzeyel venöz sistem kullanıldı. 6 hastada uç-uca, 3 hastada uç-yan anastomoz yapıldı.1 hastada arteriyel tromboz ve 1 hastada venöz tromboz gözlendi. Vasküler komplikasyon görülen bu hastalarda serbest latissimus dorsi flebi tercih edilmişti. İki hasta da erken dönem kurtarma cerrahisine alınarak anastomoz hatları yenilendi ve flepler kurtarıldı. Diğer hastalarda ek komplikasyon izlenmedi. Klinik serimizde flep kaybı yaşanmadı.&#x0D; Sonuç: Uygun vakalarda, üst ekstremite yumuşak doku rekonstrüksiyonları için serbest flepler güvenle kullanılabilir. Teknik deneyim gerektirmekle beraber, minimal donör saha problemleri nedeniyle perforatör tabanlı serbest fleplerin oldukça avantajlı olduğu ve uygun hastalarda ilk yöntem olarak güvenle seçilebileceği kanaatindeyiz.

Single centre experience with the superficial circumflex iliac artery perforator (SCIP) flap for traumatic limb defects: A case-series for first year as a regional major trauma network during a global pandemic

The free superficial circumflex iliac artery perforator (SCIP) flap evolved from the traditional groin flap, conferring numerous advantages. The thin nature of the flap avoids the need for secondary revisions and debulking procedures, particularly pertinent when theatre capacity was limited during the COVID-19 pandemic. We present a series reporting our centre's first year experiences undertaking SCIP flap reconstruction for traumatic limb injuries following the establishment of our regional major trauma network. A retrospective analysis of all patients treated for traumatic limb defects in our centre was undertaken between September 2020 to September 2021. Data was collected on patient demographics, injury, flap dimensions and flap survival. Ten patients (M:F 1:1, mean age 45 years) with traumatic limb defects were reconstructed with SCIP flaps performed by the senior authors. All had sustained open fractures. Nine had lower limb defects, most commonly at the medial ankle, one had a volar wrist defect with a devascularised hand. The mean flap dimension was 6.3 × 14.5 cm. All were anastomosed end-to-side to the recipient artery except one end-to-end anastomosis to a posterior tibial artery perforator using super-microsurgery. There was 100% flap survival. Complications consisted of one flap suffering <10% tip necrosis requiring debridement and small skin graft. The SCIP flap provides reliable, thin and pliable tissue without the need for secondary flap revisions and should be considered in the armamentarium of the reconstructive surgeon in extremity trauma reconstruction, particularly in the current environment surrounding the global pandemic. • The free superficial circumflex iliac artery perforator (SCIP) flap evolved from the traditional groin flap, conferring numerous advantages. • The thin nature of the flap avoids the need for secondary revisions and debulking procedures, particularly pertinent when theatre capacity was limited during the COVID-19 pandemic. • We demonstrate that SCIP flap provides reliable, thin and pliable tissue without the need for secondary flap revisions and should be considered in the armamentarium of the reconstructive surgeon in extremity trauma reconstruction, particularly in the current environment surrounding the pandemic.

Superficial Temporal Recipient Vessels for Craniofacial Microvascular Free-Flaps.

The selection of recipient vessels for microvascular free-flaps is critical in craniofacial reconstruction. Especially the suitability of the superficial temporal vessels is questioned conflictingly in the literature. The aim of this study was to share our experience with microvascular craniofacial free-flap reconstruction and to evaluate a set of factors that are related to the recipient vessels and to determine how these factors influence flap survival. We conducted a retrospective analysis of 39 free-flaps for craniofacial reconstruction that were performed from 2006 until 2020 and evaluated the indication for microvascular reconstruction, recipient vessels, various factors related to the recipient vessels and complications. The most utilized recipient artery was the facial artery, selected in 20 patients followed by the superficial temporal artery selected in 12 patients. The most commonly used recipient vein was the facial vein used in 16 patients, followed by the superficial temporal vein selected in 10 patients and the external jugular vein in 6 patients. Total flap necrosis occurred in one patient. There was no statistically significant association between the selected recipient vessels and patient comorbidities, major and minor complications, revision of anastomosis or flap loss. The results of our study have demonstrated that the superficial temporal artery and vein show similar results when used for face and scalp reconstruction. Considering their technical and aesthetic advantages they may be the first choice recipient vessels in established free-flap treatment algorithms for craniofacial reconstruction.

Risk Factors for Free Flap Outcomes: A Retrospective Study of 318 Free Flaps for Head and Neck Defect Reconstruction.

This study was conducted to identify the risk factors for free flap outcomes in head and neck reconstruction. A retrospective review of 318 free flaps were used for head and neck reconstructions in 317 patients over seven years. The patient characteristics, surgical data, and flap outcomes were recorded. The impact of risk factors related on the outcomes of free flaps were analyzed using single and multivariate analysis. For single factor analysis, 295 free flaps for the first reconstruction were included. Hypertension and the type of recipient vein are associated with venous thrombosis (P = .018, P = .047). Hypertension, type of free flap, recipient artery, and recipient vein were associated with the incidence of re-exploration (P = .009, P = .011, P = .017, P = .021). Hypertension had an obvious effect on the flap survival (P = .005). For multivariate analysis, hypertension (odds ratio = .166, 95% confidence interval: .043 - .636; P = .009) was a statistically significant risk factor for flap survival. For types of recipient artery and vein, selecting two venous anastomosis (one of IJVS and one of EJVS) had the minimum incidence of venous thrombosis (2.2%), and selecting facial artery, single vein (one of IJVS), and two veins (one of IJVS and one of EJVS) for anastomosis had lower incidence of re-exploration, which were 4.4%, 2.9%, and 6.0%, respectively (P < .05). Risk factors as hypertension, type of free flap, recipient artery and vein should be paid more attention in the free flaps for head and neck reconstructions. We believe proper measures will lead to better results in head and neck reconstruction.

Optimization of Vascular Supply in Free Flaps for Head and Neck Reconstruction: Analysis of a Young Team’s Experience

BackgroundFor head and neck reconstructive procedures, free flap survival depends on microsurgical and anatomical choices besides multimodal clinical management. The aim of the present study is to identify relevant variables for flap survival in our initial consecutive series.MethodsA single-center, novel reconstructive team consecutive surgical series was revised. The outcome was analyzed in terms of flap survival observing variables considered more relevant: flap type, recipient artery, vein(s), and graft interposition were discussed for facial thirds to be reconstructed. Statistical analysis was performed with Chi-square, Mann–Whitney, and Odds ratio.ResultsA total of 118 free flaps were performed in 115 microsurgical procedures (93.9% for malignancies) on 109 patients, with a flap survival rate of 91.5%. For reconstruction of the middle and lower third of the face, the facial artery was privileged, because it was already transected during lymph node dissection in order to save the superior thyroid artery for further microsurgical needs. Flap failure was 50% venous. Double vein anastomosis was not related to flap survival. Deep venous drainage (as the internal jugular vein system) required fewer revisions. Half of the re-explorations saved the flap. Grafts were a risk for flap survival. Bony flaps were more critical.ConclusionAt comparable reconstructive quality, flap choice should avoid a vascular graft. The facial artery is a preferable recipient vessel, since it saves other arteries both in the case of an arterial revision and in the case of recurrence, for further free flap reconstruction. For venous anastomosis, a deep venous recipient is safer, since it offers the possibility to choose the level of anastomosis optimizing the vascular pedicle geometry. A close postsurgical flap monitoring is advisable up to 7 days postoperatively to allow for timely flap salvage.

Hypothyroidism After Using Superior Thyroid Artery as A Recipient Artery.

Superior thyroid artery (SThA) is a common recipient artery in free tissue transfer even after total pharyngolaryngoesophagectomy (TPLE) with hemithyroidectomy. The aim of this study was to evaluate whether the use of SThA as a recipient vessel affect thyroid function in patients undergoing TPLE with hemithyroidectomy. From 2011 to 2020, 91 patients who underwent free jejunum transfer after TPLE with hemithyroidectomy were divided into two groups. In Group1 (n=47), the contralateral SThA was used for the anastomosis. In Group2 (n=44), other vessels were used. Retrospective chart review was performed comparing postoperative thyroid function between two groups. In group1, 17 patients presented hypothyroidism, 21 presented latent hypothyroidism and 9 presented no thyroid dysfunction comparing 15, 19, and 10 respectively in group 2. There were no significant differences between the two groups. Even after hemithyroidectomy, with inferior thyroid arteries are preserved, the SThA can be used as a recipient vessel. 3 Laryngoscope, 133:557-561, 2023.

Arterial Anastomosis Using Microsurgical Techniques in Adult Live Donor Liver Transplant: A Focus on Technique and Outcomes at a Single Institution.

Microvascular hepatic artery reconstruction (MHAR) is associated with decreased rates of hepatic artery thrombosis (HAT) in living donor liver transplantation (LDLT). There is a paucity of literature describing the learning points and initiation of this technique at the institutional level. The objective of this study is to report our institutional experience using MHAR in adult LDLT with a focus on technique and outcomes. A retrospective review of adult patients who underwent LDLT from January 2012 to December 2020 was conducted. Patients were divided into two groups, those who underwent LDLT without MHAR and with MHAR. We analyzed cases for technical data including donor and recipient artery characteristics, anastomotic techniques, intraop events, and postop complications. A Mann-Whitney test was performed to compare outcomes between non-MHAR and MHAR patients. Fifty non-MHAR and 50 MHAR patients met inclusion criteria. Median age at transplantation was 58 (interquartile range [IQR] 11.8) and 57.5 years (IQR 14.5), respectively. Median follow-up for MHAR patients was 12.8 months (IQR 11.6). The most common recipient arteries were the right hepatic artery (HA) (58%) and left HA (20%). Median size of recipient and donor arteries were 3.3 mm (IQR 0.7) and 3.1 mm (IQR 0.7), resulting in a median mismatch size of 0.3 mm (IQR 0.4). Median microanastomosis time was 44 minutes (IQR 0). HAT, graft failure, and mortality rates were higher in the non-MHAR cohort (6% vs. 0%, 8% vs. 0%, and 16% vs. 6%, respectively); however, these did not reach statistical significance. This study found lower rates of HAT and graft failure after implementing MHAR, though statistical significance was not achieved. Larger cohort studies are needed to further assess the potential benefit of MHAR in adult LDLT. From our experience, MHAR requires cooperation between the transplant and microsurgical teams, with technical challenges overcome with appropriate instrumentation and planning.

Artery Reconstruction in Right Lobe Living Donor Liver Transplantation: Donor-Recipient Vessel Ratio Is Key to Choosing Recipient Artery.

The aims of this study were to investigate if recipient artery choice in right lobe living donor liver transplant affects postoperative complications and discuss solutions accordingly. Three hundred fourteen right lobe living donor liver transplantation patients were divided into 2 groups: 163 patients using right hepatic artery as the recipient vessel and 151 patients using left hepatic artery as the recipient vessel. Cases involving 2 recipient blood vessels or the use of other blood vessels as recipient vessels were excluded. Overall vascular embolism rate in both groups was 1.3%, and our complication rate was lower than those in previous studies. There was no significant difference in complication rate between the groups, but a significant difference in recipient/donor artery size ratio was noted. Although left hepatic artery's anatomical position makes it less affected by bile duct anastomosis and thus fewer postoperative complications, we believe that the ratio of the donor-recipient blood vessel size and the length of the anastomosis vessel stumps are the key factors that affect the outcome of the vascular anastomosis.

A Preliminary Report of One-Session Treatment with Cranioplasty and Superficial Temporal Artery-Middle Cerebral Artery Bypass for Hemorrhagic Moyamoya Disease Patients with Skull Defect

The objective of this study was to conduct a retrospective analysis of the safety and efficacy of one-session treatment with cranioplasty and superficial temporal artery-middle cerebral artery (STA-MCA) bypass after decompressive craniectomy in hemorrhagic moyamoya disease (MMD). From March 2019 to August 2021, 5 patients with hemorrhagic MMD after DC were admitted in Nanfang Hospital. All patients underwent digital subtraction angiography to exclude any spontaneous revascularization between the cortex and temporal muscle and the preservation of STA. Then one-stage treatment with STA-MCA bypass and cranioplasty were performed. If no suitable recipient artery was available, an encephalo-myo-synangiosis procedure was used as a salvage plan. Four patients underwent direct STA-MCA bypass, while one underwent encephalo-myo-synangiosis due to absence of a suitable recipient artery. All patients had no hemorrhage on postoperative computed tomography, and no new infarcts were detected on magnetic resonance imaging. There were no new recurrent symptoms at clinical follow-up 8 to 24 months after surgery. Three patients had improved Glasgow Outcome Scale scores, and 2 patients had stable Glasgow Outcome Scale scores. Perfusion computed tomography showed improvement in cerebral hemodynamics. Four follow-up digital subtraction angiographies were performed, suggesting graft patency. One-session treatment with extracranial to intracranial bypass and cranioplasty are safe and effective in patients with MMD who have undergone previous decompressive craniectomy due to hemorrhagic attack.