Venous Anastomoses in Anterolateral Thigh Flaps for the Lower Extremity

Abstract

BackgroundDual venous drainage for anterolateral thigh flaps has been proposed to protect against flap-related complications in head and neck applications. Here we report our experience with single vs dual venous anastomosis during lower extremity free-tissue transfer.MethodsAll free anterolateral thigh flaps for lower extremity reconstruction from 2011 to 2017 were retrospectively reviewed. An algorithm was used to determine the type and number of venous anastomoses, emphasizing patient anatomy, venous quality, and size match. Patients were divided into single- and dual-venous-anastomosis groups. Univariate analysis determined differences between the groups. A multivariable analysis identified independent risk factors.ResultsFifty patients met the inclusion criteria. Patient demographics, recipient sites, wound type, and flap characteristics were similar in 1 and 2 vein groups. Average follow-up was 9.6 months. Forty-two percent underwent single venous drainage anastomoses. Mean age was 52.7 years, 78.0% were male, and 60% had defects of the foot and ankle. Increased flap area and early dangling did not increase flap demise. Thirty-three percent of single-drainage patients and 31.0% of dual-drainage patients had a complication. A body mass index of greater than 30 kg/m2 was a predictor for both flap complication (P = 0.025) and partial flap loss (P = 0.031) in univariate analysis. No independent predictors were found in multivariate analysis.ConclusionsThe number of venous anastomoses, area, and dangling protocol did not influence outcomes while using our lower extremity vein method. Thoughtful evaluation of venous egress should outweigh the routine use of multiple veins in perforator flap reconstructions of the lower extremity.

One or two venous pedicles by anastomoses for free flaps in reconstruction of the lower extremity: A systematic review and meta‐analysis

“…Reconstruction of traumatic injuries was described in two studies (29%) (Stranix et al, 2016; 2018). Four studies (57%) described mixed etiology wounds (Heidekrueger et al, 2016; Khan et al, 2020; Lorenzo et al, 2011; Mattos et al, 2018), and a single study (14%) did not specify the type of lower limb injury/wound (Hallock, 2000).…”

“…One proposed method to reduce venous congestion is the addition of a secondary vein (Hallock, 2000; Lorenzo et al, 2011; Matthews et al, 2018; Stranix et al, 2016; 2018). Secondary venous anastomosis is thought to decrease venous resistance and therefore maintain venous flow at lower pressure gradients (Mattos et al, 2018; Stranix et al, 2016). Additionally, a secondary anastomosis provides alternative drainage in the case when the primary outflow tract is obstructed (Stranix et al, 2016).…”

Comparing Outcomes of Single Versus Double Venous Anastomosis in Free Flap Operation for Lower Extremity Defect Reconstruction: A Meta-Analysis

“…After the first exclusion, researchers reviewed full-texts for the remaining 10 studies. Finally, eight articles [16][17][18][19][20][21][22][23] with a total of 1,434 flaps were included in the systematic review (Fig. 1).…”

“…Further, Lorenzo et al [22] found that using the deep vein system is more important than using two vein anastomosis, and also reported more partial flap loss for two vein anastomosis. Mattos et al [18] also insisted that using the deep venous system is more important than using double venous anastomosis technique. However, Stranix et al [19] showed that dual venous anastomosis had protective effects against flap failure.…”

Skin grafting the vascular pedicle: a useful technique to avoid microvascular collapse in free tissue transfer for limb salvage

“…However, in settings of critical limb ischemia or compromised in-flow an end to side anastomosis was performed. We have previously studied an algorithm for venous anastomosis and preferentially utilize the deep venous system, avoiding refluxing veins and matching for size [8] .…”