Utilization of Postanastomotic Side Branches for the Assessment of Anastomotic Patency

The patency of the microvascular anastomosis is the most important issue by a successful microvascular reconstruction.[1] The main reason of anastomotic failure is thrombosis, which commonly occurs due to endothelial damage.[2] There are various methods for checking the anastomotic patency used both in the perioperative and postoperative period.[3] The milking test is the most commonly performed method used for intraoperative assessment of anastomotic patency which is easy to perform and gives the surgeon the opportunity to control the blood stream under direct vision.[4] This test is performed a few centimeters distal to the anastomosis.[5] However, the study of Petry et al showed that milking test causes endothelial cell loss and thus increases the risk of anastomotic failure.[6]

Here we perform a simple trick making it safe for a surgeon to perform the milking test. Side branches of arteries and vena in suitable length located at the postanastomotic area are marked with microvascular clamps or 8–0 nylon suture and used for the milking test. In this way, the possible endothelial damage just a few centimeters distal to the microvascular anastomosis is prevented ([Fig. 1]). These side branches may also be used for perioperative cannulation and irrigation of the microvascular anastomosis.[7] We also suggest clipping of the side branch after performing the milking test to prevent the risk of clot formation because of the endothelial damage caused by the test.

Fig. 1 The schematic appearance of the method. A vessel branch with adequate diameter located in the postanastomotic area is prepared and used for performing the traditional milking test.

This method is used in our institution since 2010 in various types of microvascular tissue transplantations and extremity replantations without any complication. However, it is not always possible to find suitable postanastomotic side branches with adequate caliber to perform the milking test.

The utilization of postanastomotic side branches for the assessment of anastomotic patency is an easy, useful, and versatile method providing the surgeon to perform the safer milking test. It has also facilitated performing the milking test safely by preventing any possible damage to the microvascular anastomosis and the postanastomotic area.

• References

• 1 Huang Y, Ibrahim Z, Tong D , et al. Microvascular anastomosis guidance and evaluation using real-time three-dimensional Fourier-domain Doppler optical coherence tomography. J Biomed Opt 2013; 18 (11) 111404
• 2 Saçak B, Sirinoğlu H. A new and useful method to prevent spasm of microvascular anastomosis in the postoperative period. Microsurgery 2012; 32 (6) 505
• 3 Demiralp CO, Serel S, Zeyrek T, Demirseren ME, Ergun H, Yormuk E. New end-to-end microvascular anastomosis with geometrically adaptable ends technique: an experimental study on rats. Bratisl Lek Listy (Tlacene Vyd) 2011; 112 (9) 483-487
• 4 Pignatti M, Benati D, Cavadas PC. Effect of the two-wall-stitch mistake upon patency of rat femoral vein anastomosis: Preliminary observations. Microsurgery 2004; 24 (4) 339-344
• 5 Kuo YR, Yang KD, Huang MN, Wei FC, Jeng SF. Reactive thrombocytosis without endothelial damage does not affect the microvascular anastomotic patency. Ann Plast Surg 2003; 50 (1) 57-63
• 6 Petry JJ, French TS, Wortham KA. The effect of the “patency test” on arterial endothelial surface. Plast Reconstr Surg 1986; 77 (6) 960-964
• 7 Yesiloglu N, Sirinoglu H. Using incidental side branches of vessels for intraoperative cannulation and irrigation of the microvascular anastomosis. J Reconstr Microsurg 2014; 30 (3) 215-216