How to manage calcified vessels for head and neck microsurgical reconstruction

Abstract

Head and neck reconstructive microsurgery in patients with calcified vessels (atherosclerosis 2 or radiotherapy) is challenging. Preoperative reconstruction planning should meticulously 3 evaluate the pedicle length and caliber aiming to select the most adapted free flap type and to plan the need for harvesting two free flaps or a venous graft. During surgery, end-to-end 5 microanastomosis should be preferred, without artery clamps on calcified vessels and using 6 open-loop sutures, a limited number of microsutures and a round needle with inside-outside 7 directed bites (no atherosclerotic plaque removal). Before declamping, fibrin sealants are 8 used to prevent minor leakage around the anastomosis as well as before wound closure to fix 9 the optimal position of the pedicle avoiding pressure on the vessels or pedicle kinking. 10 Calcified vessels are not a barrier to microsurgery and do not constitute a contraindication. 11 Several options are useful to safely perform microsurgical head and neck reconstruction.

Vascular Pedicle Ossification After Jaw Reconstruction With Fibular Free Flap

“…Several groups have proposed to change the technique of harvesting fibular flap, with removal of periosteum. [18][19][20] A recent surgical study in which 20 patients had a modified harvesting procedure with removal of the fibular periosteum before vascular anastomois revealednone of these patients developed flap ossification in the 18 months following VFFF reconstruction. 2 However, the risks and benefits of these new techniques are still not well established.…”

Arterial calcification on preoperative computed tomography imaging as a risk factor for pharyngocutaneous fistula formation after total laryngectomy

“…A surgical solution to decrease the risk of PCF in high‐risk patients may be to use a pectoralis major overlay flap to reinforce the suture line of the neopharynx by covering it with healthy muscle 31 . In reconstructive microsurgery, radiological evidence of atherosclerosis may also aid in choosing the optimal flap for reconstruction 32 …”

“… 31 In reconstructive microsurgery, radiological evidence of atherosclerosis may also aid in choosing the optimal flap for reconstruction. 32 …”

The Impossible Anastomosis: Intima-to-adventitia Suture Technique for Microanastomosis of Severely Calcified Arteries

“…These include choosing a site relatively free of plaque formation, smoothing the arterial end before anastomosis, using venous bypass grafts, using a round needle while limiting the number and the tension of microsutures, directing the bites from the inside to the outside, and eversion of vessels during anastomosis to prevent the adventitia from getting caught in the lumen. 1,[5][6][7] We present a case of severe atherosclerosis of the inferior epigastric artery, making microvascular transplantation of an msTRAM flap for autologous breast reconstruction unfeasible with the above-mentioned conventional techniques. A novel microvascular suturing technique was established to salvage the microanastomosis of the calcified and extremely fragile inferior epigastric artery.…”