Controversies in Venous Anastomosis: A Critical Analysis of Choice of Recipient Vein, Number of Outflows, Style and Technique

Introduction: There are many controversies among the microsurgeons regarding the venous anastomosis. Considerable areas of debate include the choice of recipient vein (superficial versus deep system), style of anastomosis (end-to-end versus end-to-side), number of outflows (one vein versus two vein), and the technique of anastomosis (hand-sewn versus coupler). Some report superiority of one over the other, whereas others report no difference in rates of venous thrombosis or flap failure. We report our experience from a single surgeon’s data to analyze the outcomes of the various types and styles of venous anastomosis.

Methodology and Material: Single surgeon experience of consecutive 227 microsurgical reconstructions between 2006 and 2014 were retrospectively evaluated. There were 149(65%) head and neck, 48(21%) extremity and 30(13%) breast reconstructions. The choice of recipient vein (superficial versus deep system), style of anastomosis (end-to-end versus end-to-side), number of outflows (one vein versus two vein), and technique (hand-sewn versus coupler) were compared within each group and overall. The outcome is determined as rate of venous thrombosis, take back rate and total flap failure. For statistical analysis Student t-test and Mann-Whitney U tests were used within SPSS version 16.

Results: Total flap failure was 7(3%). Of these, venous related flap loss was 5(2.2%). There was no statistical difference in regards to venous thrombosis, anastomotic patency, take back rates and total flap failure among the groups (p < 0.05). Although there was no statistical difference between hand-sewn and coupler anastomosis, there was a trend to a higher success rate when coupler was used.

Conclusions: The strength of this study is its origin from single surgeon’s data with consistent microsurgical technique, patient selection and postoperative care. We identified that there were no differences between groups in regards venous thrombosis, anastomotic patency, take back and total flap failure rates. The choice of the recipient vein, style and technique of the anastomosis should be made according to the overall condition and availability of the vessel, lay of the pedicle, accessibility to the coupler and surgical judgment. Thus meticulous surgical technique and adherence to principles of microsurgery, close observation in the postoperative period and patient care are the ultimate determinates of flap survival.