Comparison of Outcomes of End-to-End versus End-to-Side Anastomoses in Lower Extremity Free Flap Reconstructions

Abstract

Background Whether to perform an end-to-end (ETE) versus end-to-side (ETS) arterial anastomosis is an integral part of preoperative planning and intraoperative decision making in free flap-based reconstructions. This study evaluated the impact of microsurgical anastomotic technique on outcomes of lower extremity reconstructions, with a focus on patients with peripheral arterial disease (PAD). Methods Over a 6-year period, 425 patients underwent 437 microvascular lower extremity free flap reconstructions with fasciocutaneous anterolateral thigh- or gracilis muscle flaps at a single surgical center. The cases were divided into an ETE (n = 297 patients) versus ETS (n = 128 patients) group according to the anastomotic technique. A retrospective analysis of patients' demographics, perioperative details, surgical complications, free flap types, recipient sites, flap survival, and the potential impact of PAD on outcomes was performed. Patient groups were comparable regarding comorbidities, American Society of Anesthesiologists scores, types of performed free flaps and recipient sites. Results We found no significant differences between the ETE versus ETS groups regarding the rate of major or minor complications (p > 0.05). Specifically, in patients suffering from PAD (n = 64) the type of arterial anastomosis had no effect on the outcome. Conclusion Overall, no significant differences in outcomes were observed when comparing the types of performed arterial anastomosis. This observation also held true for the subgroup of patients with PAD. Given that an ETS anastomosis did not increase the risk to encounter complications while preserving distal perfusion, we believe that this technique is the method of choice, especially in patients with impaired vascular status.

Evaluation of the American Society of Anesthesiologists Physical Status Classification System in Risk Assessment for Lower Extremity Reconstruction with Free Tissue Transfer

“…End-to-end versus end-to-side arterial anastomosis: There are not enough data to suggest that the end-to-side technique is preferable to the end-to-end technique. 38 However, the risks of sacrificing a native artery in an end-to-end anastomosis in limb surgery may outweigh the benefits, 33 and therefore we routinely performed end-to-side arterial anastomosis. 5.…”

Performing Distance Measurements in Curved Facial Regions: A Comparison between Three-Dimensional Surface Scanning and Ultrasound Imaging

“…1 While some of the defects resulting from such tumor extirpation can be closed by simple, intermediate, or complex repair, a large number result in tissue deficits that require flap reconstruction. [2][3][4][5][6] Flap design depends on a plethora of factors; however, initial surgical planning always needs to ensure proper vascularization and blood supply of the flap. 7 Ultrasound imaging is a commonly used tool to visualize the course of vessels prior to surgery and to facilitate the planning…”

The Double Stitch Everting Technique in the End-to-Side Microvascular Anastomosis: Validation of the Technique Using a Randomized N-of-1 Trial

“…Studies show the noninferiority of the ETS anastomosis compared with end-to-end anastomoses. 5,6 The former, however, has the added benefit of preserving distal flow, and not sacrificing a vessel leads to a more anatomically sound reconstruction. In patients with an impaired vascular status, because distal perfusion is preserved, the ETS technique has added benefits, especially for patients with impaired vascular status.…”

“…In patients with an impaired vascular status, because distal perfusion is preserved, the ETS technique has added benefits, especially for patients with impaired vascular status. 5 Many modifications to the ETS technique have been described so far, but very few have been validated, either in the laboratory or clinically. Validation is of utmost importance to assess the value of a newly described technique.…”