A simple free flap strategy using end-to-side anastomosis to the main vessels in injured extremity

Abstract

Background: During free flap surgery, the surgeon sometimes encounters problems with anastomosis such as intractable arterial spasms or vessel size discrepancy in venous anastomoses. End-to-side (ETS) anastomosis has the advantages of limited chance of vessel spasm and easy handling by adjusting for vessel size discrepancy. We introduced the arterial and venous end-to-side anastomosis (AV-ETS) strategy, which is based on the ETS anastomosis to the main artery and accompanying veins, to avoid intraoperative anastomotic problems when creating a free flap. The aim of this study was to compare flap outcomes and intraoperative anastomotic problems before and after introduction of the AV-ETS strategy in extremity free flap surgery.

Materials and methods: We retrospectively examined 72 consecutive extremity free flaps. Before introducing the AV-ETS strategy, we used the conventional strategy in which the recipient artery was selected according to the number of the remaining main artery and the anastomosis technique was flexibly changed, although the end-to-end (ETE) technique was used in most cases.

Results: The conventional group had 18 flaps and the AV-ETS group had 54 flaps. The rate of flap survival did not differ between these groups, and there were no cases of flap failure after the introduction of the AV-ETS strategy. The AV-ETS group had significantly fewer flaps that required a change in preoperative planning for the recipient artery or anastomotic site of the artery.

Conclusions: The AV-ETS strategy may facilitate reliable preoperative planning and the performance of stable free flap surgery without requiring a flexible response during surgery.

Keywords: End-to-side anastomosis; Extremities soft tissue defect; Free flap; Main artery; Recipient vessel; Strategy.

Figure 1

A diagram showing the AV-ETS strategy. The main artery and accompanying veins that travel closest to the soft tissue defect and had good blood flow were selected as the recipient vessels, and all anastomoses were performed using the ETS technique regardless of the number of remaining main arteries. AV-ETS, arterial and venous end-to-side anastomosis; ETS, end-to-side.

Figure 2

A representative case showing the use of intact vessels as the recipient vessels in the AV-ETS group. A: A 35-year-old man was stabbed by the blade of a mowing machine and experienced an open tibial shaft fracture with crushed muscle in the right lower leg. B: Diagram showing the free flap surgery using the AV-ETS strategy. Soft tissue reconstruction using a latissimus dorsi flap and internal fixation using an intramedullary nail were performed 4 days after the injury. C: The intact tibialis posterior artery and the accompanying vein were selected as the recipient vessels, and arterial anastomosis (arrow) and venous anastomosis (arrowhead) were performed using the MPETS technique. D, E: The postoperative finding just after and 13 months after free flap surgery. The flap survived without any postoperative problems, and good function was obtained after tendon reconstruction surgery. AV-ETS, arterial and venous end-to-side anastomosis; MPETS, microscopic parachute ETS.

Figure 3

A representative case showing the use of the injured vessels as the recipient vessels in the AV-ETS group. A: A 31-year-old man experienced an open fracture dislocation of the right Lisfranc joint after falling from a high place. After debridement and internal fixation surgery, soft tissue reconstruction was performed using an anterolateral thigh flap 10 days after the injury. B: Diagram showing the free flap surgery using the AV-ETS strategy. C: A site with sufficient blood flow proximal to the injured stump of the dorsalis pedis artery was selected as the recipient vessel and an arterial anastomosis (arrow) and two venous anastomoses (arrowheads) were performed using the MPETS technique. D, E: The postoperative finding just after and 1 year after free flap surgery. The flap survived completely without any postoperative problems, and good contour was obtained after defatting procedure. AV-ETS, arterial and venous end-to-side anastomosis; MPETS, microscopic parachute ETS.