The utility of the microvascular anastomotic coupler in free tissue transfer

Abstract

T he transfer of autogenous, vascularized free-tissue is a cornerstone of modern reconstructive surgery, particularly when dealing with extensive oncological ablations and large post-traumatic defects. A half-century after Jacobson and Suarez (1) described the first sutured microvascular anastomosis, the cumulative efforts of surgeons and researchers have refined free tissue transfer (FTT) into a reliable modality that often provides excellent cosmetic and functional results.In addition to adequate presurgical planning and meticulous dissection technique, the microvascular anastomosis is critically important for successful reconstruction. The reported success rate of FTT ranges from 91% to 99%, with the majority of failures being due to technical errors with vessel anastomosis (2). Indeed, a hand-sewn anastomosis is a technically demanding procedure, particularly when dealing with veins, which prompted investigation into alternative strategies to suture. One example is the microvascular anastomotic coupling device (MACD), an interlocking ring-pin design that is becoming more widely used in FTT. Initial animal studies demonstrated favourable tensile characteristics and healing of coupled vessels (3), and subsequent case series in head and neck, breast and limb reconstructive surgery have reported favourably on MACD utilization. These case series have been limited by smaller numbers and variability in reconstructive subsites; however, recently, several larger series have been published. We sought to systematically review the literature to examine the utility of MACD use in FTT with regard to success rates and optimal applications of this device. MethodsA search of PubMed, Ovid MEDLINE, and EMBASE databases (inception to January 2011) was performed using major search terms including "microvascular anastomotic coupler", "anastomotic device", "venous coupler", "Nakayama ring pin" and "free tissue transfer". Two independent reviewers performed the title and abstract review, identifying relevant articles for retrieval. Inclusion criteria were MACD utilization and FTT reconstruction. There was no limitation placed on BACKGrouNd:The microvascular anastomosis remains a technically sensitive and critical determinant of success in free tissue transfer. The microvascular anastomotic coupling device is an elegant, friction-fit ring pin device that is becoming more widely used. oBJeCtive: To systematically review the literature to examine the utility of the microvascular coupler in free tissue transfer. Methods: A comprehensive database search was performed to identify eligible publications. Inclusion criteria were anastomotic coupler utilization and free-tissue transfer. Recorded information from eligible studies included patient age, follow-up, radiation history, number of free-flaps and failure rates, reconstruction subsites, number of coupled venous and arterial anastomoses, coupling time, conversion to sutured anastomosis, coupler size and thrombosis rates. results: Twenty-five studies reporting on 3207 patients were inc...

Free jejunal flap transfer with multiple vascular pedicles for safe and reliable pharyngoesophageal reconstruction

“…Anastomoses of arteries and veins are usually completed in 22 (arterial anastomosis) and 25 (venous anastomosis) minutes by manual suture, or can be performed in 5 minutes using an anastomotic coupling device for veins. [38][39][40] That is, to perform anastomosis of an artery-vein pair, this procedure requires only an additional 47 minutes with manual suture, or 27 minutes with a coupling device. In fact, at our institution, anastomosis of a primary artery and vein, and an additional artery and vein, required an average of 37 and 42 minutes, respectively, in 15 recent cases (our recorded time includes manipulations under the microscope such as vessel preparation before starting anastomosis).…”

Reduced venous thrombosis and re‐exploration time with anastomotic coupling device: A cohort study

“…3 However, there is considerably less variation in reported venous patency rates with ACD. 3,4 The ACD is thought to improve the consistency of venous anastomoses, 3 and reduce complications. 5 However, no comparative study to date has demonstrated the hypothesized decrease in flap complications.…”

“…We agree with previous authors that ACD is consistently faster than hand-sewn strictly in time to complete venous anastomoses. 3,4,8 In our study, we measured total procedure times to reflect system level operative resources. In analyzing re-explorations due to venous insufficiency, times were significantly shorted for flaps performed initially with ACD.…”

“…Times were recorded in minutes, from procedure start to end; this excluded associated time for "patient in" and "patient out" of operating room, or "anesthesia start" and "anesthesia end." A number of previous case series have already measured specific coupling time, 3,4 with improved speed reduced variability versus hand-sewn. 8 Overall procedure times were selected to demonstrate the system level time saving of operative resources for elective cases and reexplorations.…”

Salvage arterial anastomosis using a microvascular coupler in head and neck free flap reconstruction

“…Commonly cited advantages of the coupler over suture anastomosis are reduced operative time, reliable vessel eversion, and avoidance of intraluminal thrombogenic material. [1][2][3] However, couplers are more commonly used for venous compared to arterial anastomosis, 4 likely secondary to more favorable vessel characteristics and multiple studies demonstrating suboptimal results in coupled arterial anastomosis. [5][6][7] Flap-related complications are often attributed to errors in microvascular anastomotic technique and include inadequate vessel eversion resulting in luminal exposure of thrombogenic adventitia, uneven suture placement leading to anastomotic leak or stasis, and unrecognized backwalling causing stenosis and thrombosis.…”