Venous Anastomosis Research Articles

Is it really necessary to perform venous anastomosis in vascularized corticoperiosteal bone flap? A randomized prospective 4-year follow-up study

BackgroundThis study aims to investigate the treatment results of atrophic nonunion of the lower and upper limb with vascularized bone flaps performed with only arterial anastomosis versus the execution of flaps performed with arterial and venous anastomosis, comparing the surgical time and the healing rate of these two techniques. Methods49 patients were enrolled in this study and were randomly divided into two groups: group A, the control group, consisted of 27 patients, who underwent vascularized corticoperiosteal bone flap with both arterial and venous anastomosis; group B, consisted of 22 patients, who underwent vascularized corticoperiosteal bone flap with only arterial anastomosis. The surgical time, the time to harvest the graft and the microsurgical time were evaluated. Radiological and clinical follow-ups were performed with one independent and blinded investigator to avoid bias. ResultsA significant reduction in the duration of the intervention in group B was found: a 13.63% reduction of the total surgical time and a 41.75% reduction of the microsurgical time. A significant difference was not found between groups A and B in bone healing time. All the patients of both groups were able to return to their daily life activities. ConclusionsOur investigation suggests that it isn't necessary to perform the venous anastomosis between the flap pedicle and the recipient area. Presumably, the venous blood flow reaches the systemic circulation through the vascular bone marrow network. Our procedure avoids venous trauma during the dissection and execution of the anastomosis and, therefore, can minimize complications such as venous thrombosis.

The effect of single or multiple arteries in the donor kidney on renal transplant surgical outcomes.

As the number of end-stage renal disease (ESRD) patients is increasing, but there are not enough living donors, it is necessary to broaden the criteria for candidates who can undergo donor nephrectomy. Thanks to surgeons' increasing experience with laparoscopic donor nephrectomy (LND), multiple renal artery grafts, previously considered a relative contraindication to donor nephrectomy, have become candidates for LDN. We aimed to compare the outcomes of donors and recipients with single artery and with multiple arteries in LDN. A total of 214 patients were included in the study. Patients were divided into two groups according to the number of donor arteries: donors with one artery (group 1) and donors with multiple arteries (group 2). The number of donor arteries, operative time, warm ischemia time (WIT), cold ischemia time (CIT), arterial anastomosis time, venous anastomosis time, the extent of bleeding, and preoperative complications were recorded to evaluate the preoperative data. The mean operation time in group 1 was 90.3 ± 11.8min, while in group 2, it was 102.1 ± 5.5min (p = 0.000). WIT group 1 was 90.9 ± 4.3s and group 2 100.6 ± 2.1s (p = 0.000). Arterial anastomosis time was 12.25 ± 3.8 in group 1 and 22.5 ± 4.5 in group 2 (p = 0.000). No statistically significant difference was found between the two groups in other parameters. Increasing the number of donor arteries in renal transplantation (RT) operations prolonged the operation time on both the donor and recipient sides. Still, it had no negative impact on complications or graft function in the postoperative period.

A tactics for treating large skin wounds on the head

An open wound on the head is an injury (skin tear) of all scalp external layers including dermis, subcutaneous fatty tissue, aponeurosis, muscles, vessels and nerves with intact skull bones and intact neurological reactions [1].Extensive wounds of the external head layers, in addition to a standard threat to the human health, bear an additional risk due to their close localization to the brain. Because of the abundant blood supply to scalp soft tissues, high rate of volumetric blood flow (50–60 milliliters per 100 g of brain tissue), numerous extra-, intracranial arterial and venous anastomoses, there is a real danger of spreading the infection inside the skull and developing meningitis or encephalitis.Problems of care of patients with extensive head wounds, risk of complications that can cause severe consequences determine the relevance of the issue presented in this work.Objective. To analyze treatment results of patients admitted to the emergency department of Mariinskaya State City Hospital in St. Petersburg within three months in 2021 and to develop an optimal tactics for treating patients with extensive wounds of the scalp.Material and research methods. 2245 patients with various types of head injury were admitted to the hospital; 610 (27.2 %) of them had damage of the external scalp layers. Each patient had standard clinical and laboratory examination and multislice computed tomography (MSCT) examination of the head at 64-slice Definition AS (Siemens, Germany) CT scanner. In the emergency department, all patients who were injured by high-energy traumatic objects had the primary surgical debridement; all patients who were injured by low-energy traumatic objects had wound toilet and wound suturing. Three most representative cases with extensive wounds of the external scalp (over 10 cm) with illustrations are presented in the article as clinical examples.Results. All patients had good outcomes. There were no any signs of wound infection either.Conclusion. A thorough primary surgical debridement of scalp wounds with their drainage followed by observation and treatment in the hospital is a necessary condition for successful healing of large scalp wounds.

Utilizing the Retrograde Flow of Internal Mammary Vessels as a Donor Pedicle.

Introduction The aim of this study is to assess the results of retrograde flow of internal mammary artery and vein (IMA/V) as a donor vessel for free flap microvascular anastomosis (MVA). This need arises with bipedicle deep inferior epigastric perforator (DIEP) flaps, when all four zones with extra fat need to be harvested for unilateral breast reconstruction coupled with poor midline crossover of circulation naturally or because of midline scar. Large anterolateral thigh flaps for chest wall cover, with multiple perforators from separate pedicles, also need supercharging. This needs an additional source of donor vessels, antegrade IMA/V being the first one. Materials and Methods Retrospective study of microvascular breast reconstruction using retrograde internal mammary donor vessels. Results Out of 35 cases, 20 cases had distal IMA/V, with retrograde flow, as donor vessel for second set of arterial and venous anastomosis. In two cases, retrograde IMA/V was used for the solitary set of MVA. In remaining 13 cases, either retrograde IMA or V was utilized either as a principal or accessory donor. No flap was lost. Venous and arterial insufficiency happened in one case each, both were salvaged. Two cases developed partial necrosis, needing debridement and suturing. One case developed marginal necrosis. Only one case developed fat necrosis with superadded infection on follow-up. Conclusion Distal end of IMA and IMV on retrograde flow is safe for MVA as an additional or sole pedicle. It is convenient to use being in the same field. It enables preservation of other including thoracodorsal pedicle and latissimus dorsi flap for use in case of a complication or recurrence.

Technical Tips for Anastomosis of 0.2-mm Diameter Vessels during Lymphatic Venous Anastomosis.

Technical Tips for Anastomosis of 0.2-mm Diameter Vessels during Lymphatic Venous Anastomosis.

A dorsalis pedis venous flap containing a U-shaped venous arch for the reconstruction of fingertip defects.

In small-area soft tissue defects of the fingers, venous flaps have the advantages of easy design and harvesting, and also a thin and flexible texture. Although the artery-vein-vein (A-V-V) pattern is the safest pattern, the tiny veins in the finger pulp make anastomosis difficult. We have designed a modified blood flow pattern flap using the dorsum of the foot as the donor site and anastomosing the U-shaped blood vessels in the venous flap with the two digital arteries in an artery-vein-artery (A-V-A) pattern to reconstruct the digital arterial arch without the need for venous anastomosis. Our study included 22 patients with 23 fingertip defects. In the 23 fingers, 18 flaps survived completely and four had only partial marginal necrosis. The donor site healed well without significant scar hyperplasia.Level of evidence: IV.

V05-02 SINGLE PORT ROBOT-ASSISTED EXTRAPERITONEAL KIDNEY TRANSPLANTATION: TIPS AND TRICKS

You have accessJournal of UrologyCME1 May 2022V05-02 SINGLE PORT ROBOT-ASSISTED EXTRAPERITONEAL KIDNEY TRANSPLANTATION: TIPS AND TRICKS Aaron Kaviani, Jihad Kaouk, Mahmoud Abou Zeinab, Alp Tuna Beksac, Ethan Ferguson, Yi-Chia Lin, Alvin Wee, and Mohamed Eltemamy Aaron KavianiAaron Kaviani More articles by this author , Jihad KaoukJihad Kaouk More articles by this author , Mahmoud Abou ZeinabMahmoud Abou Zeinab More articles by this author , Alp Tuna BeksacAlp Tuna Beksac More articles by this author , Ethan FergusonEthan Ferguson More articles by this author , Yi-Chia LinYi-Chia Lin More articles by this author , Alvin WeeAlvin Wee More articles by this author , and Mohamed EltemamyMohamed Eltemamy More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002579.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Multiport transperitoneal robot-assisted kidney transplant is performed in few centers across the globe. We introduced the single-port robot-assisted extraperitoneal kidney transplantation using the da Vinci SP platform (Intuitive Surgical, Sunnyvale, CA USA) in 2019. In this video, we aimed to provide detailed tips and tricks for the surgical steps of this approach. METHODS: Thirteen patients underwent single-port robot-assisted kidney transplantation. The patients are placed in the supine position with the bed slightly flexed, tilted toward the left side, and put in a 15° Trendelenburg position. A 5-cm infraumbilical incision is made. The extraperitoneal space is developed. The robot is docked per the floating docking technique. The external iliac artery and vein are dissected off lymphatics. Benching of the kidney is performed. LigaSure device (Medtronic, Dublin, Ireland) is used to dissect the vessels. The posterior surface of the artery and the vein are marked for better intracorporal orientation. A 14 cm ureteral stent is placed. A 3-0 chromic suture is placed in the lower pole for nephropexy. Kidney is wrapped with a blue glove with cut-off fingers covering the lower pole. A 12 mm port is placed through the same incision and 400 mL of ice is introduced. The kidney is then introduced. The venous and arterial anastomoses are performed using 6-0 GORE-TEX® sutures (Gore Medical, Flagstaff, AZ, USA). An 8-inch suture is used for each anastomosis and it is tied on itself at the distal and proximal corners. Bulldog clamps (Scanlan, Saint Paul, MN, USA) are used for vascular control. Arteriotomy is made using a sleeve-protected scalpel. Aortic punch is introduced directly through the abdominal wall. After completion of the anastomosis, the kidney is repositioned to the space above the psoas muscle. Ureteroneocystostomy is performed using 4-0 Vicryl sutures. The kidney is fixed to the lateral abdominal wall. The robot is undocked and the wound is closed. RESULTS: Surgery was successfully completed in all patients without conversion to open surgery or adding extra ports. There were no intra or postoperative complications greater than Clavien grade 2. There was no delayed graft function. Median (IQR) vein and artery anastomosis times were 26 (24-28) and 37 (33-40) minutes. Patients stayed in the hospital for 2–3 days. Mean (SD) creatinine at 6 and 12 months were 1.31 (0.24) and 1.30 (0.16) mg/dL. CONCLUSIONS: We demonstrated detailed tips and tricks for steps of the single-port robot-assisted extraperitoneal kidney transplantation. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e516 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aaron Kaviani More articles by this author Jihad Kaouk More articles by this author Mahmoud Abou Zeinab More articles by this author Alp Tuna Beksac More articles by this author Ethan Ferguson More articles by this author Yi-Chia Lin More articles by this author Alvin Wee More articles by this author Mohamed Eltemamy More articles by this author Expand All Advertisement PDF DownloadLoading ...

Our experience with the anterior interosseous artery fasciocutaneous flap for local and distant soft tissue reconstructions

Martin and his colleagues in 1989 described for the first time a fasciocutaneous flap based on a posterior branch of the anterior interosseous artery (AIA). Despite its promising characteristics, this flap never achieved popularity and the literature about it is limited. The aim of the present study is to share our experience with the AIA flap both as a local and free flap in reconstructing defects of various body regions. A retrospective review of 26 consecutive patients operated between January2001 and August 2020 was conducted. Seventeen male and nine female patients, mean age 52 years, underwent reconstruction of local and distant soft tissue defects using the AIA flap. Fourteen flaps were raised as free flap and 12 as local flaps for a total of 26 flaps. The locations of the defects included the face, the lower limb, the hand dorsum, and fingers. Twenty-four out of 26 flaps survived completely, and two pedicled flaps presented partial necrosis, with one requiring a new free flap procedure. One free anterior interosseous flap required revision of the venous anastomosis. Two donor site dehiscence were observed, and they both healed by secondary intention healing. Follow-ups were conducted for a mean of 18 months. All patients showed good contour restoration of the affected body part. The AIA flap, either free or pedicled, represents a reliable tool to perform "like-with-like" reconstructions of hand defects. In some occasions, it is well suited for shallow defects in other body parts.

The Multiple-U Technique: A Novel Microvascular Anastomosis Technique That Guarantees Everted Anastomosis Sites with Solid Intima-to-Intima Contact.

The key to successful microvascular anastomosis is achieving intima-to-intima contact, which is not always easy. In this article, the authors propose the multiple-U technique, which is a novel microvascular anastomosis technique that characterizes easy and reliable intima-to-intima contact. The technique was performed on patients who underwent free flap reconstruction for head and neck defects at the Kaohsiung Chang Gung Memorial Hospital from September 1, 2020, to November 30, 2020. The immediate patency test results for all vessel anastomoses were positive, and the postoperative recovery courses of the patients were without any vascular complications. In conclusion, the multiple-U technique is a widely available technique that guarantees everted anastomosis sites and solid intima-to-intima contact. This technique can be performed on both arterial and venous anastomoses regardless of vessel size and wall thickness.

The arterialised saphenous venous flow-through flap for managing the radial forearm free flap donor site.

BackgroundThe radial forearm fasciocutaneous flap (RFFF) is a workhorse flap, however concerns with donor site morbidity include tendon exposure, delayed wound healing, impaired sensitivity, and poor cosmesis, have seen it fall out of favor. We present a method of using an arterialised saphenous flow through flap to reconstruct the RFFF donor site.MethodA cohort study of six patients (five male, one female; mean age 59 [range 19–90]) who had their RFFF donor site reconstructed with an arterialised saphenous flow through flap is presented. The use of multiple peripheral efferent venous anastomoses, flap rotation 180 degrees prior to inset, and the ligation of intra‐flap connecting veins were three modifications employed. Primary outcomes include complication rates. Secondary outcomes were patient reported outcome measures via the Michigan Hand Outcomes Questionnaire, and patency and flow through the flap.ResultsIn all six cases, there was flap survival. RFFF dimensions ranging from lengths of 6–15 cm (mean 11.5 cm) and widths of 4–6 cm (mean 5.3 cm), with an average flap area of 58 cm2 (range 24–90). There were no total flap losses, one partial superficial flap loss and one minor donor site delayed healing, over a mean follow‐up of 6 months (4–24 months). The average overall patient satisfaction was 91 on Michigan Hand Outcomes Questionnaire. Pain was well tolerated with a low average pain score of 15.ConclusionThe modified arterialised saphenous flow through flap is a useful option for reconstructing the soft tissue defect and reconstituting the radial artery after RFFF harvest.

Reconstruction of Large Full-Thickness Abdominal Wall Defects Using a Free Functional Latissimus Dorsi Muscle

IntroductionThe large full-thickness abdominal wall defect has to be treated by considering anatomical and functional requirements. The abdominal wall must regain total physiological function, which means that the full thickness abdominal wall defect must be reconstructed anatomically, not only according to the anatomical requirements but also maintaining the functional dynamic voluntary movement. Defects in the abdominal wall alter respiratory mechanics and can impair the diaphragm function. Additionally, muscles of the anterolateral abdominal wall increase the stability of the lumbar region of the vertebral column by tensing the thoracolumbar fascia and by increasing intraabdominal pressure.Materials and MethodsThe timing and method of reconstruction must be chosen depending upon the etiology of the defect. Severe traumatic injuries, abdominal wall infections, necrotizing soft tissue loss, or sepsis needs to undergo staged reconstruction following adequate debridement to control the infectious process, establish the zone of injury, and for proper treatment of intraabdominal pathology, thereby achieving temporary primary closure using split-thickness skin grafting to the viscera. At the time of definitive reconstruction, deep skin graft dermabrasion give us a facial-like layer with adequate strength to stabilize the static abdominal wall. This dermal layer is supported by free functional (innervated) latissimus dorsi muscle (fLDM), giving full anatomical coverage and functional stability. After oncologic resections full-thickness abdominal wall reconstruction was performed immediately with a combination of fLDM flaps and meshes.ResultsA total of 14 patients underwent abdominal wall reconstruction using the fLDM flap. Staged reconstruction was applied in 8 cases. In the remaining six cases, two had no mesh support, three had synthetic mesh, and one had a fascial graft, which were covered with fLDM flap. There were no free flaps failure. One flap revision due to venous anastomosis thrombosis was performed. Donor site seromas occurred in 5 cases and were treated with punction and direct doxycycline injection. Electromyographic testing postoperatively confirmed reinnervation of transplanted LDM.ConclusionUsing fLDM as a definitive solution, we are not only able to repair soft tissue defects, but also reconstruct voluntary contractility and dynamic natural functional abdominal wall. Transplanted LDM offers enough contractile capacity and strength to replace the function of the missing abdominal wall muscles.

Superficial Temporal Vein and Alternative Middle Temporal Vein as Recipient Veins for Free-flap Reconstruction.

Summary:The superficial and middle temporal veins (STV and MTV) have been used as recipient veins for free-flap reconstruction; however, the STV is sometimes small and cannot be used, while the MTV is not fully recognized or utilized as a recipient vein. The purpose of the present study was to evaluate the reliability of the STV/MTV as recipient veins and to verify the utility and availability of the MTV by comparing the two veins. Thirty-five consecutive cases of free-flap reconstruction utilizing recipient vessels in the temporal region were retrospectively reviewed. Regarding recipient veins, the STV was the only option in the first 18 cases; the MTV was included among the options in the latter 17 cases. The calibers of the STV/MTV were evaluated at two level points (1: zygomatic arch, 2: palpebral fissure) using the results of preoperative dynamic-enhanced computed tomography (CT). Two cases of severe venous congestion were identified among the first 18 patients. After the adoption of the MTV, the MTV was used in 10 of the 17 cases, and no vascular complication occurred. On CT imaging evaluation, the caliber of the MTV (Point 2) (2.94 ± 0.55 mm) was significantly larger than the calibers of the STV (Point 1) (2.40 ± 0.48 mm) and MTV (Point 1) (2.49 ± 0.43 mm) (both P < 0.001). Regarding the recipient veins in the temporal area, the MTV can offer an option with a larger caliber or for additional venous anastomosis when the condition of the STV is inadequate.

Pre-existing Systolic Dysfunction is the Most Powerful Predictor of Failed Arteriovenous Fistula Maturation

Patients requiring hemodialysis access creation often have significant comorbid conditions, which may impact access maturation. Underlying cardiac dysfunction likely plays an important role in the maturation of arteriovenous fistulae (AVF). The effect of specific parameters of cardiac function on successful AVF creation has not previously been explored. A retrospective chart analysis of patients undergoing first-time AVF creation at a single center from 2011 to 2018 was performed. Patients with a transthoracic echocardiogram within the 12months prior to surgery were included. Standard demographic and perioperative variables were collected, in addition to echocardiographic and vascular mapping data. The primary outcome was access maturation, defined as the use of the access site for hemodialysis at 3, 6, and 12months after surgery. A total of 121 patients met inclusion criteria with a cumulative AVF maturation rate of 57% (69/121) in this select population. Patients with pre-existing systolic cardiac dysfunction were more than 5 times less likely to see their AVF mature by one year postsurgery (OR=0.17, P=0.018). Preoperative venous diameter, access site location, and the type of fistula did not differ significantly between patients with and without systolic dysfunction. Selection of the cephalic vein as the venous anastomosis and diastolic dysfunction (≥ Grade 2) were also associated with lower rates of access maturation, although these associations were less robust. Systolic cardiac dysfunction is the most important nonmodifiable variable associated with failed AVF maturation. Patients requiring hemodialysis with significant pre-existing cardiac dysfunction may not be appropriate for permanent access creation, and long-term catheter use should be seriously considered as an alternative.

Flowthrough Omental Flap for Vascularized Lymph Node Transplant of the Lower Extremity.

Vascularized lymph node transplantation is a surgical approach for the treatment of chronic lymphedema. However, there is no clinical standard for flap placement nor vascular anastomoses. The authors propose a novel flowthrough configuration for an omental vascularized lymph node transplant in the popliteal space. To prepare the popliteal space for an omental free flap, the medial popliteal fat pad and medial head of the gastrocnemius muscle were debulked. Venous anastomoses were completed with vein couplers, joining the right gastroepiploic vein to the medial sural venae comitantes and the left gastroepiploic vein to the lesser saphenous vein. Arterial anastomoses were hand sewn, joining the right gastroepiploic artery to the proximal medial sural artery and the left gastroepiploic artery to the distal medial sural artery, to create the flowthrough configuration. A retrospective review of patients who underwent this procedure at a single institution was performed. Six patients with chronic lymphedema of the lower extremity underwent vascularized lymph node transplantation from June of 2019 to November of 2020. Five patients underwent at least 3 months of postoperative surveillance, with no postoperative complications reported. In this technique contribution, the authors describe a novel flowthrough configuration for an omental free flap to the popliteal space. The popliteal space offers an aesthetically favorable recipient location when appropriately prepared. The medial sural vessels are ideal recipient vessels for the flowthrough omental flap. Therapeutic, IV.

Microsurgical anastomosis using anterior versus posterior tibial artery in lower limb free tissue transfer.

Soft tissue lower limb reconstruction often requires free tissue transfer. We investigated whether the target vessels used for micro-vascular anastomosis in the lower limb influences microsurgical outcomes. Data from Plastic Surgery Departments of a major tertiary hospital in the United Kingdom (Leeds General Infirmary, LGI) and Australia (Princess Alexandra Hospital, PAH) were retrospectively analysed. Patients who underwent lower limb free flap reconstruction using the posterior (PTA) or anterior tibial artery (ATA) were included. Patient demographics, free flap and microvascular anastomosis details were analysed. Primary outcome was flap failure. Secondary outcome was return to theatre. Two hundred and thirty-four free flaps were included (PAH 115; LGI 119). 60% were muscle flaps. Eighty-one percent of patients were male, with trauma the cause in 82%. PTA was used for microsurgical anastomosis in 70% of cases. Venae comitantes were preferred (96%) for venous anastomosis. PTA group showed a higher proportion of patients with trauma as the mechanism of injury. ATA group was more likely to have an end-to-end arterial anastomosis configuration. Total flap loss was 3.8%. There was no clinically significant difference in flap failure or return to theatre using ATA versus PTA. Incidence of lower limb free flap failure is low (<5%) and not influenced by use of ATA versus PTA for microsurgical anastomosis. The choice of target vessels for microsurgical reconstruction of the lower limb should be predicated upon factors other than aversion to one or another vessel. If all other microsurgical considerations are equal, the surgeon can exercise personal preference.

Prospective, Multicenter Clinical Study of the Covera Vascular Covered Stent in the Treatment of Stenosis at the Graft-Vein Anastomosis of Dysfunctional Hemodialysis Access Grafts

PurposeTo study the use of the self-expanding Covera covered stent for the treatment of stenotic lesions at the venous anastomosis of hemodialysis arteriovenous grafts (AVGs). Materials and MethodsA total of 110 patients with AVG venous anastomotic stenosis of ≥50% and access dysfunction were treated at 14 centers in the United States using percutaneous transluminal angioplasty followed by covered stent placement. The primary end points were 30-day safety and 6-month target lesion primary patency (TLPP). The secondary measures included access circuit primary patency, circuit cumulative patency, and the number of reinterventions through 24 months. ResultsFreedom from a primary safety event at 30 days was 96.4% while the 6-month TLPP rate was 70.3%. Seventy-five patients completed 24-month follow-up (68.2%). The TLPP rates were 54.2% at 365 days and 36.9% at 730 days while the access circuit primary patency rates were 16.7% at 365 days and 7.8% at 730 days (Kaplan-Meier analysis). The access circuit cumulative patency rates were 85.4% at 12 months and 73.6% at 24 months. The number of reinterventions to maintain the patency of the access circuit was 3.6 ± 3.1 at 24 months (1.6 ± 1.9 at the target lesion). ConclusionsUse of the Covera covered stent for hemodialysis graft-vein anastomotic stenosis provided a safe treatment option with a TLPP rate of 70.3% at 6 months and TLPP and cumulative access circuit patency rates of 36.9% and 73.6% at 2 years.

Cephalic vein transposition in head-and-neck reconstruction

The advent of free flaps has made it possible to undertake increasingly complex reconstructive surgeries. Many of the patients have already undergone extensive prior surgery, primary free flap reconstruction and/or cervical irradiation. These treatments strongly impact anatomy and tissue quality. The reconstructive surgeon may be faced with a situation where the choice of recipient vessels is limited; in 7% of cases, no cervical vessels are available at all. For venous anastomosis, branches of the internal and external jugular vein are preferentially used, but may have been ligated or be unusable. Venous congestion is one of the most common causes of failure in these situations. The cephalic vein has been described as an alternative for second anastomosis in first line, but is rarely used for early free-flap salvage. Based on a case study, the technique of cephalic vein transposition is illustrated for early salvage of a double free flap for head-and-neck reconstruction. This technique is simple, reliable and rapid. It should be part of the armamentarium of the head and neck reconstructive surgeon.

Upgradation of Lymph Supermicrosurgical Skills through Lymphatic Venous Anastomosis

Upgradation of Lymph Supermicrosurgical Skills through Lymphatic Venous Anastomosis

Delineating the risk factors of venous congestion: An analysis of 455 deep inferior epigastric perforator flaps with radiographic correlation

Venous congestion occurs in 2-15% of DIEP flaps for breast reconstruction. We previously showed that thicker suprascarpal fat pads are associated with increased SIEV caliber and may, by extension, indicate a dominant superficial venous system. In this study, we aim to provide clinical correlation and to determine the risk factors of venous congestion in order to identify high-risk patients who may benefit from prophylactic SIEV dissection. An IRB-approved retrospective study was performed in patients who underwent DIEP flap reconstruction from August 2011 to August 2020. Radiographic measurements of suprascarpal fat pad thickness and SIEV diameter were collected per hemi-abdomen from preoperative imaging. The statistical analysis explored whether certain variables were associated with venous congestion. A total of 258 patients underwent 455 DIEP flaps. Suprascarpal fat pad thickness was positively correlated with SIEV diameter (r=0.51, p<0.001), each with a mean caliber of 19.8mm and 2.5mm, respectively. Seven flaps (1.5%) developed venous congestion, with five requiring SIEV salvage and secondary venous anastomosis. Congested flaps had significantly thinner suprascarpal fat pads (12.3vs. 20.0mm, p=0.043). All six congested flaps with imaging had suprascarpal thickness less than 18mm, compared to 182 out of 335 non-congested flaps with imaging (p=0.035). The risk of venous congestion following DIEP flap reconstruction is significantly increased with thinner suprascarpal fat pads, suggesting that the mechanism of venous congestion may not be limited to superficial venous dominance. We recommend prophylactic SIEV dissection in all patients with suprascarpal fat pad thickness less than 18mm.

Applying the Microvascular Anastomotic Coupler Device to End-to-side Venous Anastomosis in Reconstructive Surgery

Background:Microsurgical vascular anastomosis plays an important role in successful free-tissue transfer. The Microvascular Anastomotic Coupler Device (MACD) aims to simplify anastomosis and decrease the time spent on this step, thereby reducing surgeon stress and improving the overall quality of the surgery, especially when venous end-to-side anastomosis is required. Our comparative retrospective cohort study aimed to determine the effect of this widely used device on anastomosis times and complications in head and neck/esophageal reconstruction cases involving venous end-to-side anastomosis using the internal jugular vein as the recipient vessel.Methods:All consecutive patients who underwent head and neck/esophageal reconstruction with hand-sewn or MACD-mediated venous end-to-side anastomosis using the internal jugular vein by three experienced microsurgeons in our tertiary-care hospital in 2012–2020 were identified. Venous anastomosis times and venous trouble cases were recorded.Results:Of the 191 cases, 44 and 147 underwent hand-sewn and MACD-mediated anastomosis respectively. The average venous anastomosis times of these groups were 31 and 11 minutes, respectively. Venous trouble was observed in two hand-sewn (4.5%) and four MACD (2.7%) cases, respectively. Vein twisting and improper coupler placement were the causes in the latter four cases.Conclusions:This study confirmed that MACD simplifies end-to-side venous anastomosis and reduces the time spent on this procedure. Also, for safer anastomosis, it is necessary to pay attention to preventing twisting and improper coupler placement when using MACD. We believe the MACD can improve the quality of reconstructive surgery.