Iatrogenic Pseudoaneurysm Following Reverse Radial Forearm Free Tissue Transfer

Abstract

The appearance of a pseudoaneurysm in a free flap is an extremely rare complication in microsurgery. Yet, although uncommon, this occurrence still poses a dilemma as to the most effective mode of treatment. Treatment modalities consist of surgical exploration, embolization, and endovascular stenting. We present a case of arterial pedicle pseudoaneurysm following free tissue transfer of a radial forearm flap for a cranial defect. We describe our successful operative treatment of the pseudoaneurysm as well as review the literature regarding the applicability of the described treatments. We conclude that a critical evaluation of factors including the timing of arterial inflow loss, the necessity of the pedicle, the condition and quality of the recipient site, and the possibility of neovascularization can assist in determining the proper intervention and maximizing success.

Microvascular anastomotic aneurysms in the clinical setting: Case report and review of the literature

“…However, in one case aneurysm formation was attributed to a technical error in the anastomosis. 17 Finally in our case also, aneurysm formation was attributed to the patients poorly controlled systemic hypertension. As for other etiologic factors reported for vessels of diameter larger than 5 mm, no cases of microvascular anastomotic aneurysm formation due to the suture material used or anastomotic tension were found.…”

“…Regarding the significantly higher incidence of microvascular anastomotic aneurysms in experimental studies, when compared with the clinical setting, this can be attributed to the thinner vascular wall and its more fragile elastic component, as well as the relatively high blood pressure and the rapid pulse rate in rats. 5,6 As far as the type of anastomosis was concerned, the incidence of aneurysm formation was twice as high in the end-to-side 8,13,16,17 when compared with the end-toend technique. 9,11 However, the small number of cases prevents us from making a conclusive statement.…”

“…These cases are listed and presented in detail in Table 1. [8][9][10][11][12][13][14][15][16][17] According to the data collected, all the aneurysms were false, and the main etiologic factor was infection, because in the majority of the reported cases (90%) early postoperative infection was present in the area. However, in one case aneurysm formation was attributed to a technical error in the anastomosis.…”

“…Another sign, usually appearing in later stages is reported to be the presence of a pulsating mass in the anastomosis area, but given the size of the vessels, this might be not clinically detectable. 8,13,17 Because of the lack of data from case series in the literature, and the absence of widely accepted therapeutic guidelines, the treatment of the aforementioned cases was tailored to each specific clinical presentation. The treatment was done on an emergency basis in the case of rupture [10][11][12][14][15][16] or was elective when a pulsating mass was present.…”

“…The treatment was done on an emergency basis in the case of rupture [10][11][12][14][15][16] or was elective when a pulsating mass was present. 13,17 Treatment of ruptured aneurysms aimed primarily to bleeding control. In the majority of these cases, emergency surgical exploration was performed and a microvascular clamp was applied to the bleeding nutrient artery.…”