Selection of deep or superficial recipient vein in lower extremity reconstruction using free flap: A systematic review and meta‐analysis

Shimbo, Keisuke; Kawamoto, Haruka; Kannan, Ruben Y.

doi:10.1002/micr.30946

Cited by 6 publications

(5 citation statements)

References 16 publications

(32 reference statements)

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“…Patient No. [13][14][15][16][17]. In these patients, DVT was discovered in the recipient veins of the ALTP flap in two patients and in the donor veins in three patients.…”

Section: Resultsmentioning

confidence: 89%

“…However, most experienced surgeons recommended performing two venous anastomoses if possible ( 16 ). Furthermore, the incidence of thrombosis following venous anastomosis is generally lower in deep vein anastomosis than in superficial vein anastomosis ( 17 ). Therefore, one artery and two deep veins between the flap pedicle and the recipient vessel are usually connected in free tissue transfer to the lower extremities.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Deep vein thrombosis in donor or recipient veins encountered during lower extremity reconstruction with a free anterolateral thigh perforator flap: How do we deal with it?

et al. 2022

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BackgroundThe free anterolateral thigh perforator (ALTP) flap has been successfully adopted to reconstruct traumatic soft tissue defects in the lower extremities. However, the occurrence of deep vein thrombosis (DVT) in donor or recipient veins has been overlooked, and there has been no reliable guideline to manage it. Therefore, in this study, we review our cases where the ALTP flaps were transferred to traumatic lower limbs even though DVT was found in the pedicle or recipient veins. Furthermore, based on our experiences, we suggest an algorithmic approach for dealing with DVT.Patients and methodsThis study included 108 patients who underwent lower extremity reconstruction using a free ALTP flap between January 2014 and January 2021. All medical records were reviewed, including preoperative assessment data, intraoperative findings, and postoperative complications. Notably, when DVT was found in both the donor and recipient veins, we thoroughly assessed operative findings, surgical solutions, and final outcomes.ResultsSixty-one of 108 (56.4%) patients underwent computed tomographic venography (CTV) preoperatively, revealing DVT in 11 of these 61 (18%) patients. Three of these 11 patients had iliofemoral DVT, and surgery was delayed more than two weeks after detection. The remaining eight patients had calf DVT and underwent free ALTP flap transfer as scheduled. Conversely, 47 of 108 (43.6%) patients did not undergo CTV, and an occult DVT was found in five of these 47 (10.6%) patients. In two of these five patients, free flap surgery was replaced with amputation and local flap coverage. In the remaining three patients and one patient with an occult DVT that was not found on CTV, the free ALTP flap transfer was carried out. In 15 patients with DVT, free ALTP flap transfer was performed using various alternative methods for venorrhaphy. Consequently, all flaps survived, with partial necrosis occurring in two patients.ConclusionIf DVT-affected veins are appropriately managed, the free ALTP flap can be successfully transferred to the traumatic lower limb even when DVT occurs in donor or recipient veins. The author's algorithm can help surgeons overcome the insufficiency of veins for pedicle anastomosis due to DVT and avoid postoperative thromboembolic complications.

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“…Patient No. [13][14][15][16][17]. In these patients, DVT was discovered in the recipient veins of the ALTP flap in two patients and in the donor veins in three patients.…”

Section: Resultsmentioning

confidence: 89%

Section: Discussionmentioning

confidence: 99%

Deep vein thrombosis in donor or recipient veins encountered during lower extremity reconstruction with a free anterolateral thigh perforator flap: How do we deal with it?

et al. 2022

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“…In these situations, superficial veins are used for anastomosis (Rodriguez Lorenzo et al, 2011). Meta‐analysis by Shimbo, Kawamoto, and Koshima (2022) concluded that the vascular thrombosis was significantly lower in deep veins when compared to superficial vein but had comparable rates of flap loss/necrosis. In our study irrespective of the number of veins or the system of veins used for anastomosis the results was not statistically significant difference.…”

Section: Discussionmentioning

confidence: 99%

“…In these situations, superficial veins are used for anastomosis (Rodriguez Lorenzo et al, 2011). Meta-analysis by Shimbo, Kawamoto, and Koshima (2022) Successful outcome of the ALT free flap does not depend on the number of vein anastomosis or the system of vein anastomosis selected. However, large number of studies using superficial vein alone for anastomosis as first choice will prove their efficacy as a recipient vessel.…”

Section: Fiftymentioning

confidence: 99%

A comparative study of clinical outcome in ALT free flap reconstruction using superficial or deep and single or dual recipient vein anastomosis in different sites

Nagabhushanaiah,

Srinivas,

Parasuramulu

et al. 2023

Microsurgery

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Background: During the free flap surgery obtaining a suitable recipient vein is an important factor for successful outcome. As in all other flaps even in ALT flap, single or double venous anastomosis, superficial or deep venous anastomosis is still a matter of debate among the micro vascular surgeons. Though dual vein anastomosis is a time-tested method, single vein anastomosis has the advantage of reducing the operative time and hospitalization cost. Similarly, in situation where the deep veins are dubious superficial veins are savior. This study explores the outcome of ALT flap using different system of recipient veins. Patients and Methods: Retrospective analysis of the 54 free ALT flaps performed over a period of 5 years from June 2017 till June 2022, was carried out. Out of 54, 38 (63%) were male patients and 16 (37%) were females. The outcome of the flaps was evaluated in single or dual anastomosis group. Similarly, the outcome of the flaps with deep or superficial vein anastomosis was also evaluated. The flaps outcomes are evaluated as favorable (successful as well as partial loss are considered as favorable) and unfavorable (complete loss of the flap).Results: Among the 54 flaps, 31 patients had lower limb reconstruction, majority were post-traumatic defects. Twenty patients had head and neck reconstruction following post malignancy excision. Three patients had upper-limb reconstruction for post traumatic and burn injury defects. The outcome was analyzed. Twenty patients had dual vein anastomosis, 90% (18 out of 20) of patients had favorable outcome and 10% (2 out of 20) had unfavorable outcome. Thirty-four patients underwent single vein anastomosis, 94% had favorable outcome and 6% had unfavorable outcome.The result was not statistically significant as p < .05. Seven patients underwent superficial vein recipient anastomosis, and all flaps were (100%) successful and no failure, whereas out of 27 patients who had undergone deep vein anastomosis 25 (92%) had favorable outcome and 2 (8%) had unfavorable outcome. The results were not statistically significant as p > .05.

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“…Contrary to patients whose main reason is the malignancy for reconstruction such as head and neck patients, the trauma (76.1%) (Shimbo et al, 2022) is the most important reason of lower extremity injuries. So, the operated group in lower extremity injuries is generally consist from productive ages as young and middle‐aged adults (Lee, Stranix, et al, 2019).…”

Section: Discussionmentioning

confidence: 99%

Simultaneous sequential anterolateral thigh free flaps with interposition comitant vein graft for one‐stage lower extremity reconstruction: A case report

2023

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Developments in the microsurgery have made perforator fasciocutaneous free flaps more popular in lower extremity reconstructions. They have acceptable donor site morbidities when compared to traditional methods. However; there are some possible limitations with these flaps such as anatomical variations and insufficiency to cover large and/or complex defects with a single flap. Anterolateral thigh flap (ALT), which has proven its advantages in the reconstruction of many regions of the body, is one of the versatile perforator fasciocutaneous flap options. We present our experience of using sequential double ALTs for complex lower extremity reconstruction. A 44‐year‐old patient, who had a history of multiple traumas as a result of a traffic accident, had interconnected anterior tibial (6 × 4 cm) and bimalleolar defects (4 × 4 cm, 4 × 5 cm) in his left lower extremity. Double ALT flaps (16 × 9 cm, 17 × 10 cm) were used to reconstruct three individual defects. The posterior tibial artery was the only uninjured artery perfusing the lower extremity, so the already occluded anterior tibial artery was chosen as the recipient to avoid disturbing the posterior tibial vessels. The dominant comitant vein of one of the flaps was leaving the pedicle too early and following an aberrant path with increased diameter. As it was understood that the other comitant vein had poor drainage, it was taken as an interposition vein graft to lengthen the dominant aberrant vein. The two flaps were customized as one by flow‐through anastomoses on the operating table. The anterior tibial artery was washed and debrided distal to proximal until arterial spurting was seen. At the distance of 8 cm superior, the artery was found as feasible and anastomoses were performed. The proximal flap was inset vertically and the distal flap was inset on the horizontal axis to reach the bilateral malleolar defect. No complications were observed in both flaps. The patient was followed‐up for 8 months. Despite the successful reconstruction, the patient is still unable to walk unaided due to multiple traumas and the rehabilitation process continues. We believe that the use of sequential double ALT may be a useful alternative to reconstruct large lower extremity defects with minimal donor site morbidity when a suitable single recipient vessel is available.

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Selection of deep or superficial recipient vein in lower extremity reconstruction using free flap: A systematic review and meta‐analysis

Cited by 6 publications

References 16 publications

Deep vein thrombosis in donor or recipient veins encountered during lower extremity reconstruction with a free anterolateral thigh perforator flap: How do we deal with it?

Deep vein thrombosis in donor or recipient veins encountered during lower extremity reconstruction with a free anterolateral thigh perforator flap: How do we deal with it?

A comparative study of clinical outcome in ALT free flap reconstruction using superficial or deep and single or dual recipient vein anastomosis in different sites

Simultaneous sequential anterolateral thigh free flaps with interposition comitant vein graft for one‐stage lower extremity reconstruction: A case report

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