Late Extrusion of a Venous Microvascular Coupling Ring

Mechanical coupling is a reliable and efficient method for performing microvascular venous anastomosis that has gained widespread use and is associated with high patency rates and low rates of postoperative thrombosis.[1] [2] [3] Despite extensive use, to our knowledge there have not been any published reports detailing coupler-related complications other than venous thrombosis. This report details the case of a late extrusion of a venous coupling ring and successful management of this problem by excision of the device.

A 62-year-old man with stage IV base of tongue cancer, treated by chemoradiation protocol (radiotherapy dose unknown) 5 years earlier, presented with osteoradionecrosis of the left mandible unresponsive to serial debridements and hyperbaric oxygen therapy. He underwent left segmental mandibulectomy and reconstruction with a right fibula osteocutaneous free flap in 2007 with an uneventful postoperative course. Two coupled venous anastomoses were performed to branches of the internal jugular vein. Two years later, the patient presented with osteoradionecrosis of the right mandible. He underwent metachronous right segmental mandibulectomy reconstructed with a left fibula osteocutaneous free flap. Two venous couplings were performed, a 3-mm ring used for a branch of the internal jugular vein and a 4-mm ring used to couple the external jugular vein. His postoperative course was uneventful. Two years later, the patient presented for routine follow-up with complaints of “something poking out” of his neck for several weeks. On exam, partial extrusion of a venous coupler ring through his right neck was noted ([Fig. 1]). Intraoral examination and Panorex radiographs revealed viable flaps with complete osteosynthesis. We subsequently performed exploration of his right neck, with removal of a 4-mm venous coupler ring and ligation of the (thrombosed) vein.

Fig. 1 Coupler ring partially extruding through the right neck.

Since their introduction into clinical practice about 30 years ago, microvascular anastomotic coupling devices have been recognized as a reliable, effective, and efficient means of performing venous microvascular anastomoses.[1] [2] [3] [4] [5] Even in the setting of head and neck reconstruction, when patients have often received previous radiation, large series have demonstrated low thrombosis rates and few if any other complications attributable to the devices.[4] [5] Despite the ubiquitous use of coupling devices, we are unaware of any previous descriptions of extrusion of the coupling ring. Nishimoto et al did report two “thin patients” in their series of 98 free tissue transfers where the coupler rings were palpable beneath the skin.[5] In our case, the extrusion of the coupling ring was a function of the patient's extremely atrophic radiated skin combined with the superficial (external jugular) location of the coupler. Upon excision, the vein was noted to be scarred and without flow, presumably for a significant interval of time. Despite compromise of flow through this vein the flap remained viable likely because of the chronic nature of the extrusion and because a second venous anastomosis was performed at the time of his surgery. Although clearly a rare complication, this case serves to highlight the potential pitfalls associated with use of this device, or any foreign body, in tissue damaged by radiation.

• References

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