Subscribe to RSS
Download PDF
DOI: 10.1055/s-0038-1660831
Comparison of Hand-Sewn versus Coupled Venous Anastomoses in Traumatic Lower Extremity Reconstruction
Funding None.
Publication History
21 December 2017
26 April 2018
Publication Date:
15 June 2018 (online)
Abstract
Background Microvascular reconstruction of the lower extremity has the highest reported complication and flap failure rates of any anatomical region. Despite widespread adoption of the mechanical anastomotic venous coupler and encouraging results in other anatomical regions, there are limited reports examining its use in the lower extremity. This study compares outcomes between coupled and hand-sewn venous anastomoses in traumatic lower extremity reconstruction.
Methods Retrospective review of our institutional flap registry from 1979 to 2016 identified soft tissue free flaps performed for the reconstruction of Gustilo type IIIB/IIIC open tibial fractures. Patient demographics, flap characteristics, use of a venous anastomotic coupler, and perioperative outcomes were examined. Analysis was performed using chi-square and Student's t-tests.
Results A total of 361 patients received a microvascular free flap for coverage of a Gustilo type IIIB or IIIC tibial fracture following traumatic injury. After excluding cases that lacked adequate information on coupler use, 358 free flaps were included in the study. There were 72 (20%) free flaps performed using a venous coupler and 286 (80%) performed with hand-sewn venous anastomoses. There were comparable rates of major complications (22.2 vs. 26.1%; p = 0.522), total flap failure (6.5%, vs. 10.2%; p = 0.362), and partial flap failure (9.7 vs. 12.2%; p = 0.579) between venous coupler and hand-sewn anastomoses, respectively. Furthermore, use of the venous coupler was not associated with increased rates of operative take backs (22.8 vs. 23.0%; p = 0.974). However, reconstructions performed using a venous coupler were significantly more likely to have a second venous anastomosis performed (37.5 vs. 21.3%; p = 0.004).
Conclusion Complication and flap failure rates were similar between reconstructions performed with a venous coupler and those performed with hand-sewn venous anastomoses. These findings suggest that use of the venous anastomotic coupler is safe and effective in lower extremity reconstruction, with comparable outcomes to conventional sutured anastomoses.
Prior Presentations
None.
-
References
- 1 Harashina T. Analysis of 200 free flaps. Br J Plast Surg 1988; 41 (01) 33-36
- 2 Khouri RK, Shaw WW. Reconstruction of the lower extremity with microvascular free flaps: a 10-year experience with 304 consecutive cases. J Trauma 1989; 29 (08) 1086-1094
- 3 Denk MJ, Longaker MT, Basner AL, Glat PM, Karp NS, Kasabian AK. Microsurgical reconstruction of the lower extremity using the 3M microvascular coupling device in venous anastomoses. Ann Plast Surg 1995; 35 (06) 601-606
- 4 Medina ND, Fischer JP, Fosnot J, Serletti JM, Wu LC, Kovach III SJ. Lower extremity free flap outcomes using an anastomotic venous coupler device. Ann Plast Surg 2014; 72 (02) 176-179
- 5 Serafin D, Sabatier RE, Morris RL, Georgiade NG. Reconstruction of the lower extremity with vascularized composite tissue: improved tissue survival and specific indications. Plast Reconstr Surg 1980; 66 (02) 230-241
- 6 Hammert WC, Minarchek J, Trzeciak MA. Free-flap reconstruction of traumatic lower extremity wounds. Am J Orthop 2000; 29 (9, Suppl): 22-26
- 7 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78 (03) 285-292
- 8 Grotting JC. Prevention of complications and correction of postoperative problems in microsurgery of the lower extremity. Clin Plast Surg 1991; 18 (03) 485-489
- 9 Tsai TM, Bennett DL, Pederson WC, Matiko J. Complications and vascular salvage of free-tissue transfers to the extremities. Plast Reconstr Surg 1988; 82 (06) 1022-1026
- 10 Khouri RK. Avoiding free flap failure. Clin Plast Surg 1992; 19 (04) 773-781
- 11 Ahn CY, Shaw WW, Berns S, Markowitz BL. Clinical experience with the 3M microvascular coupling anastomotic device in 100 free-tissue transfers. Plast Reconstr Surg 1994; 93 (07) 1481-1484
- 12 Berggren A, Ostrup LT, Lidman D. Mechanical anastomosis of small arteries and veins with the unilink apparatus: a histologic and scanning electron microscopic study. Plast Reconstr Surg 1987; 80 (02) 274-283
- 13 Ostrup LT, Berggren A. The UNILINK instrument system for fast and safe microvascular anastomosis. Ann Plast Surg 1986; 17 (06) 521-525
- 14 Falconer DP, Lewis TW, Lamprecht EG, Mendenhall HV. Evaluation of the Unilink microvascular anastomotic device in the dog. J Reconstr Microsurg 1990; 6 (03) 215-222
- 15 Blair WF, Steyers CM, Brown TD, Gable RH. A microvascular anastomotic device: part I. A hemodynamic evaluation in rabbit femoral arteries and veins. Microsurgery 1989; 10 (01) 21-28
- 16 Blair WF, Morecraft RJ, Steyers CM, Maynard JA. A microvascular anastomotic device: part II. A histologic study in arteries and veins. Microsurgery 1989; 10 (01) 29-39
- 17 Gilbert RW, Ragnarsson R, Berggren A, Ostrup L. Strength of microvascular anastomoses: comparison between the unilink anastomotic system and sutures. Microsurgery 1989; 10 (01) 40-46
- 18 Nishimoto S, Hikasa H, Ichino N, Kurita T, Yoshino K. Venous anastomoses with a microvascular anastomotic device in head and neck reconstruction. J Reconstr Microsurg 2000; 16 (07) 553-556
- 19 Zhang T, Lubek J, Salama A. , et al. Venous anastomoses using microvascular coupler in free flap head and neck reconstruction. J Oral Maxillofac Surg 2012; 70 (04) 992-996
- 20 DeLacure MD, Wong RS, Markowitz BL. , et al. Clinical experience with a microvascular anastomotic device in head and neck reconstruction. Am J Surg 1995; 170 (05) 521-523
- 21 Jandali S, Wu LC, Vega SJ, Kovach SJ, Serletti JM. 1000 consecutive venous anastomoses using the microvascular anastomotic coupler in breast reconstruction. Plast Reconstr Surg 2010; 125 (03) 792-798
- 22 Camara O, Herrmann J, Egbe A, Koch I, Gajda M, Runnebaum IB. Venous coupler for free-flap anastomosis. Anticancer Res 2009; 29 (07) 2827-2830
- 23 Grewal AS, Erovic B, Strumas N, Enepekides DJ, Higgins KM. The utility of the microvascular anastomotic coupler in free tissue transfer. Can J Plast Surg 2012; 20 (02) 98-102
- 24 Ducic I, Brown BJ, Rao SS. Lower extremity free flap reconstruction outcomes using venous coupler. Microsurgery 2011; 31 (05) 360-364
- 25 Benacquista T, Kasabian AK, Karp NS. The fate of lower extremities with failed free flaps. Plast Reconstr Surg 1996; 98 (05) 834-840 , discussion 841–842
- 26 Spector JA, Levine S, Levine JP. Free tissue transfer to the lower extremity distal to the zone of injury: indications and outcomes over a 25-year experience. Plast Reconstr Surg 2007; 120 (04) 952-959
- 27 Ardehali B, Morritt AN, Jain A. Systematic review: anastomotic microvascular device. J Plast Reconstr Aesthet Surg 2014; 67 (06) 752-755
- 28 Frederick JW, Sweeny L, Carroll WR, Rosenthal EL. Microvascular anastomotic coupler assessment in head and neck reconstruction. Otolaryngol Head Neck Surg 2013; 149 (01) 67-70
- 29 Patel SA, Pang JH, Natoli N, Gallagher S, Topham N. Reliability of venous couplers for microanastomosis of the venae comitantes in free radial forearm flaps for head and neck reconstruction. J Reconstr Microsurg 2013; 29 (07) 433-436
- 30 Li R, Zhang R, He W, Qiao Y, Li W. The use of venous coupler device in free tissue transfers for oral and maxillofacial reconstruction. J Oral Maxillofac Surg 2015; 73 (11) 2225-2231
- 31 Bodin F, Brunetti S, Dissaux C. , et al. Venous coupler use for free-flap breast reconstructions: specific analyses of TMG and DIEP flaps. Microsurgery 2015; 35 (04) 295-299
- 32 Broer PN, Weichman KE, Tanna N. , et al. Venous coupler size in autologous breast reconstruction--does it matter?. Microsurgery 2013; 33 (07) 514-518
- 33 Fitzgerald O'Connor E, Rozen WM, Chowdhry M. , et al. The microvascular anastomotic coupler for venous anastomoses in free flap breast reconstruction improves outcomes. Gland Surg 2016; 5 (02) 88-92
- 34 Kulkarni AR, Mehrara BJ, Pusic AL. , et al. Venous thrombosis in handsewn versus coupled venous anastomoses in 857 consecutive breast free flaps. J Reconstr Microsurg 2016; 32 (03) 178-182
- 35 Schubert HM, Schoeller T, Wechselberger G. 1000 consecutive venous anastomoses using the microvascular anastomotic coupler in breast reconstruction. Plast Reconstr Surg 2010; 126 (05) 1789 , author reply
- 36 Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109 (07) 2219-2226 , discussion 2227–2230
- 37 Park JE, Rodriguez ED, Bluebond-Langer R. , et al. The anterolateral thigh flap is highly effective for reconstruction of complex lower extremity trauma. J Trauma 2007; 62 (01) 162-165
- 38 Yazar S, Lin CH, Lin YT, Ulusal AE, Wei FC. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plast Reconstr Surg 2006; 117 (07) 2468-2475 , discussion 2476–2477
- 39 Hong JP, Shin HW, Kim JJ, Wei FC, Chung YK. The use of anterolateral thigh perforator flaps in chronic osteomyelitis of the lower extremity. Plast Reconstr Surg 2005; 115 (01) 142-147
- 40 Hallock GG. Relative donor-site morbidity of muscle and fascial flaps. Plast Reconstr Surg 1993; 92 (01) 70-76
- 41 Maraka J, Hausien O, Abreo N, Patel NG, Durrani AJ. The microvascular coupler device for end-to-side venous anastomosis in free tissue transfer for head and neck reconstruction. J Plast Reconstr Aesthet Surg 2014; 67 (12) 1757-1758
- 42 Spector JA, Draper LB, Levine JP, Ahn CY. Routine use of microvascular coupling device for arterial anastomosis in breast reconstruction. Ann Plast Surg 2006; 56 (04) 365-368
- 43 Hanasono MM, Kocak E, Ogunleye O, Hartley CJ, Miller MJ. One versus two venous anastomoses in microvascular free flap surgery. Plast Reconstr Surg 2010; 126 (05) 1548-1557
- 44 Futran ND, Stack Jr BC. Single versus dual venous drainage of the radial forearm free flap. Am J Otolaryngol 1996; 17 (02) 112-117
- 45 Stranix JT, Anzai L, Mirrer J. , et al. Dual venous outflow improves lower extremity trauma free flap reconstructions. J Surg Res 2016; 202 (02) 235-238
- 46 Ahmadi I, Herle P, Rozen WM, Leong J. One versus two venous anastomoses in microsurgical free flaps: a meta-analysis. J Reconstr Microsurg 2014; 30 (06) 413-418
- 47 Stranix JT, Lee ZH, Anzai L. , et al. Optimizing venous outflow in reconstruction of Gustilo IIIB lower extremity traumas with soft tissue free flap coverage: are two veins better than one?. Microsurgery 2017
- 48 Heidekrueger PI, Ehrl D, Heine-Geldern A, Ninkovic M, Broer PN. One versus two venous anastomoses in microvascular lower extremity reconstruction using gracilis muscle or anterolateral thigh flaps. Injury 2016; 47 (12) 2828-2832
- 49 Lorenzo AR, Lin CH, Lin CH. , et al. Selection of the recipient vein in microvascular flap reconstruction of the lower extremity: analysis of 362 free-tissue transfers. J Plast Reconstr Aesthet Surg 2011; 64 (05) 649-655
- 50 Cho EH, Shammas RL, Carney MJ. , et al. Muscle versus fasciocutaneous free flaps in lower extremity traumatic reconstruction: a multicenter outcomes analysis. Plast Reconstr Surg 2018; 141 (01) 191-199
- 51 Stranix JT, Lee ZH, Jacoby A. , et al. Not all Gustilo type IIIB fractures are created equal: arterial injury impacts limb salvage outcomes. Plast Reconstr Surg 2017; 140 (05) 1033-1041