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DOI: 10.1055/s-0041-1723823
Vein Grafting in Microsurgical Lower Extremity Reconstruction: Outcome Analysis of Primary versus Secondary Salvage Procedures
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Abstract
Background Many microsurgeons fear high complication rates and free flap loss when vein grafting is necessary to restore blood flow at the recipient site. The aims of this study were to comparatively analyze surgical outcomes of interposition vein grafts (VG) in microsurgical primary lower extremity reconstruction and secondary salvage procedures.
Methods A retrospective study was conducted on 58 patients undergoing free flap transfers with vein grafting for primary lower extremity reconstruction (cohort 1) and secondary salvage procedures (cohort 2) between 2002 and 2016. A matched-pair analysis of both cohorts and 58 non-VG flaps was performed. Patient data, preoperative conditions, flap and vein graft characteristics, postoperative outcomes such as flap failure, thrombosis, and wound complications were analyzed.
Results A total of 726 free flap transfers were performed. In total, 36 primary reconstructions (5%) utilized 41 interposition VG (cohort 1). Postoperative vascular compromise was observed in 65 free flaps (9%). In total, 22 out of 65 secondary salvage procedures (33.8%) utilized 26 interposition VG (cohort 2). Two total flap losses occurred in each cohort (5.6 vs. 9.1%; p = 0.63). Postoperative complications were observed in 38.9% of free flaps in cohort 1 and 72.7% in cohort 2 (p = 0.01). Takeback for microvascular compromise was comparable in both cohorts (19.4 vs. 22.7%; p = 0.75). Microvascular complications occurred more often in cohort 2 (22.7%) than in cohort 1 (8.3%; p = 0.28). Lower extremity salvage rates were high among both cohorts (94.4 vs. 90.9%; p = 0.63). Matched-pair analysis did not show any relevant differences on takebacks and flap loss (p = 0.32 and p = 1.0).
Conclusion In complex lower extremity reconstructions, VG can be performed with acceptable complication rates and outcomes in primary and especially in salvage cases. With careful planning and a consistent surgical protocol, VG can provide reliable success rates in limb salvage.
Keywords
vein graft - interposition vein grafting - free flap reconstruction - lower extremity reconstructionPublication History
Received: 24 August 2020
Accepted: 22 December 2020
Article published online:
16 February 2021
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References
- 1 Norgren L, Hiatt WR, Dormandy JA. et al; TASC II Working Group. Inter-society consensus for the management of peripheral arterial disease. Int Angiol 2007; 26 (02) 81-157
- 2 Xiong L, Gazyakan E, Kremer T. et al. Free flaps for reconstruction of soft tissue defects in lower extremity: a meta-analysis on microsurgical outcome and safety. Microsurgery 2016; 36 (06) 511-524
- 3 Bayramiçli M, Tetik C, Sönmez A, Gürünlüoğlu R, Baltaci F. Reliability of primary vein grafts in lower extremity free tissue transfers. Ann Plast Surg 2002; 48 (01) 21-29
- 4 Cavadas PC. Arteriovenous vascular loops in free flap reconstruction of the extremities. Plast Reconstr Surg 2008; 121 (02) 514-520
- 5 Nemoto M, Kumazawa K, Uchinuma E, Kounoike N, Takeda A. Clinical features of primary vein grafts in free tissue transfers. Plast Surg Int 2015; 2015: 481402
- 6 Henn D, Wähmann MST, Horsch M. et al. One-stage versus two-stage arteriovenous loop reconstructions: an experience on 103 cases from a single center. Plast Reconstr Surg 2019; 143 (03) 912-924
- 7 Inbal A, Silva AK, Humphries LS, Teven CM, Gottlieb LJ. Bridging the gap: a 20-year experience with vein grafts for free flap reconstruction. the odds for success. Plast Reconstr Surg 2018; 142 (03) 786-794
- 8 Henn D, Bigdeli AK, Horsch M. et al. Venous bypass grafts versus arteriovenous loops as recipient vessels for microvascular anastomosis in lower extremity reconstructions: a matched-pair analysis. Microsurgery 2020; 40 (01) 12-18
- 9 Furr MC, Cannady S, Wax MK. Interposition vein grafts in microvascular head and neck reconstruction. Laryngoscope 2011; 121 (04) 707-711
- 10 Lin CH, Mardini S, Lin YT, Yeh JT, Wei FC, Chen HC. Sixty-five clinical cases of free tissue transfer using long arteriovenous fistulas or vein grafts. J Trauma 2004; 56 (05) 1107-1117
- 11 Nelson JA, Fischer JP, Grover R. et al. Vein grafting your way out of trouble: Examining the utility and efficacy of vein grafts in microsurgery. J Plast Reconstr Aesthet Surg 2015; 68 (06) 830-836
- 12 Cheng HT, Lin FY, Chang SC. Evidence-based analysis of vein graft interposition in head and neck free flap reconstruction. Plast Reconstr Surg 2012; 129 (05) 853e-854e
- 13 Khouri RK, Cooley BC, Kunselman AR. et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998; 102 (03) 711-721
- 14 Loos MS, Freeman BG, McClellan WT. Free muscle flap reconstructions using interpositional vein grafts vs. local anastomosis: a 5-year experience at a rural tertiary care center. W V Med J 2010; 106 (03) 19-23
- 15 Chen WF, Kung YP, Kang YC, Eid A, Tsao CK. Protocolisation and ‘end’ point of free-flap salvage. J Plast Reconstr Aesthet Surg 2012; 65 (09) 1272-1275
- 16 Chiu YH, Chang DH, Perng CK. Vascular complications and free flap salvage in head and neck reconstructive surgery: analysis of 150 cases of reexploration. Ann Plast Surg 2017; 78 (03, Suppl2): S83-S88
- 17 Nelson JA, Kim EM, Eftekhari K. et al. Late venous thrombosis in free flap breast reconstruction: strategies for salvage after this real entity. Plast Reconstr Surg 2012; 129 (01) 8e-15e
- 18 Kolbenschlag J, Daigeler A, Lauer S. et al. Can rotational thromboelastometry predict thrombotic complications in reconstructive microsurgery?. Microsurgery 2014; 34 (04) 253-260
- 19 Stern JR, Wong CK, Yerovinkina M. et al. A meta-analysis of long-term mortality and associated risk factors following lower extremity amputation. Ann Vasc Surg 2017; 42: 322-327
- 20 van Netten JJ, Fortington LV, Hinchliffe RJ, Hijmans JM. Early post-operative mortality after major lower limb amputation: a systematic review of population and regional based studies. Eur J Vasc Endovasc Surg 2016; 51 (02) 248-257
- 21 MacKenzie EJ, Bosse MJ. Factors influencing outcome following limb-threatening lower limb trauma: lessons learned from the Lower Extremity Assessment Project (LEAP). J Am Acad Orthop Surg 2006; 14 (10 Spec No.): S205-S210
- 22 Piwnica-Worms W, Stranix JT, Othman S. et al. Risk factors for lower extremity amputation following attempted free flap limb salvage. J Reconstr Microsurg 2020; 36 (07) 528-533
- 23 Stranix JT, Lee ZH, Jacoby A. et al. Not all Gustilo type IIIB fractures are created equal: arterial injury impacts limb salvage outcomes. Plast Reconstr Surg 2017; 140 (05) 1033-1041
- 24 Khouri RK, Shaw WW. Reconstruction of the lower extremity with microvascular free flaps: a 10-year experience with 304 consecutive cases. J Trauma 1989; 29 (08) 1086-1094
- 25 Zhang F, Ho PR, Chin BT, Ozek C, Buncke HJ, Lineaweaver WC. Effect of vein grafting on the survival of microvascularly transplanted muscle flaps. Microsurgery 1996; 17 (09) 512-516
- 26 Zhang F, Oliva A, Kao SD, Newlin L, Buncke HJ. Microvascular vein grafts in the rat cutaneous free-flap model. J Reconstr Microsurg 1994; 10 (04) 229-233
- 27 Jones NF, Johnson JT, Shestak KC, Myers EN, Swartz WM. Microsurgical reconstruction of the head and neck: interdisciplinary collaboration between head and neck surgeons and plastic surgeons in 305 cases. Ann Plast Surg 1996; 36 (01) 37-43
- 28 Schusterman MA, Miller MJ, Reece GP, Kroll SS, Marchi M, Goepfert H. A single center's experience with 308 free flaps for repair of head and neck cancer defects. Plast Reconstr Surg 1994; 93 (03) 472-478 , discussion 479–480
- 29 Chang EI, Nguyen AT, Hughes JK. et al. Optimization of free-flap limb salvage and maximizing function and quality of life following oncologic resection: 12-year experience. Ann Surg Oncol 2016; 23 (03) 1036-1043
- 30 Ahmadi I, Herle P, Miller G, Hunter-Smith DJ, Leong J, Rozen WM. End-to-end versus end-to-side microvascular anastomosis: a meta-analysis of free flap outcomes. J Reconstr Microsurg 2017; 33 (06) 402-411
- 31 Bigdeli AK, Thomas B, Schmidt VJ. et al. The conjoined parascapular and latissimus dorsi free flap for reconstruction of extensive knee defects. Microsurgery 2018; 38 (08) 867-875
- 32 Germann G, Bickert B, Steinau HU, Wagner H, Sauerbier M. Versatility and reliability of combined flaps of the subscapular system. Plast Reconstr Surg 1999; 103 (05) 1386-1399
- 33 Davies MG, Hagen PO. Pathophysiology of vein graft failure: a review. Eur J Vasc Endovasc Surg 1995; 9 (01) 7-18
- 34 Chang EI, Fearmonti RM, Chang DW, Butler CE. Cephalic vein transposition versus vein grafts for venous outflow in free-flap breast reconstruction. Plast Reconstr Surg Glob Open 2014; 2 (05) e141
- 35 Stewart D, Liau J, Vasconez H. Flap pedicle vena comitant as a vein graft donor source. Microsurgery 2009; 29 (02) 115-118
- 36 Avgerinos ED, Sachdev U, Naddaf A. et al. Autologous alternative veins may not provide better outcomes than prosthetic conduits for below-knee bypass when great saphenous vein is unavailable. J Vasc Surg 2015; 62 (02) 385-391
- 37 Mirzabeigi MN, Wang T, Kovach SJ, Taylor JA, Serletti JM, Wu LC. Free flap take-back following postoperative microvascular compromise: predicting salvage versus failure. Plast Reconstr Surg 2012; 130 (03) 579-589
- 38 Maricevich M, Lin LO, Liu J, Chang EI, Hanasono MM. Interposition vein grafting in head and neck free flap reconstruction. Plast Reconstr Surg 2018; 142 (04) 1025-1034
- 39 Sepehripour AH, Jarral OA, Shipolini AR, McCormack DJ. Does a ‘no-touch’ technique result in better vein patency?. Interact Cardiovasc Thorac Surg 2011; 13 (06) 626-630
- 40 Brouwers K, Kruit AS, Hummelink S, Ulrich DJO. Management of free flap salvage using thrombolytic drugs: a systematic review. J Plast Reconstr Aesthet Surg 2020; 73 (10) 1806-1814
- 41 Germann G, Steinau HU. The clinical reliability of vein grafts in free-flap transfer. J Reconstr Microsurg 1996; 12 (01) 11-17
- 42 Bryan AJ, Angelini GD. The biology of saphenous vein graft occlusion: etiology and strategies for prevention. Curr Opin Cardiol 1994; 9 (06) 641-649
- 43 Medina ND, Fischer JP, Fosnot J, Serletti JM, Wu LC, Kovach III SJ. Lower extremity free flap outcomes using an anastomotic venous coupler device. Ann Plast Surg 2014; 72 (02) 176-179
- 44 Lee ZH, Alfonso AR, Stranix JT. et al. Vein size mismatch increases flap failure in lower extremity trauma free flap reconstruction. J Reconstr Microsurg 2019; 35 (08) 587-593
- 45 Belkin M, Raftery KB, Mackey WC. et al. A prospective study of the determinants of vein graft flow velocity: implications for graft surveillance. J Vasc Surg 1994; 19 (02) 259-265 , 265–267
- 46 Sasmor MT, Reus WF, Straker DJ, Colen LB. Vascular resistance considerations in free-tissue transfer. J Reconstr Microsurg 1992; 8 (03) 195-200
- 47 Stewart SF, Lyman DJ. Effects of a vascular graft/natural artery compliance mismatch on pulsatile flow. J Biomech 1992; 25 (03) 297-310
- 48 Levin LS. The reconstructive ladder. An orthoplastic approach. Orthop Clin North Am 1993; 24 (03) 393-409
- 49 Schmidt VJ, Hirsch T, Osinga R. et al. [The interdisciplinary microsurgeon - results of the Consensus Workshop of the German Speaking Society for Microsurgery of Peripheral Nerves and Vessels]. Handchir Mikrochir Plast Chir 2019; 51 (04) 295-301
- 50 Azoury SC, Stranix JT, Kovach SJ, Levin LS. Principles of orthoplastic surgery for lower extremity reconstruction: why is this important?. J Reconstr Microsurg 2019
- 51 Patterson CW, Stalder MW, Richardson W, Steele T, Wise MW, St Hilaire H. Timing of free flaps for traumatic wounds of the lower extremity: have advances in perioperative care changed the treatment algorithm?. J Reconstr Microsurg 2019; 35 (08) 616-621
- 52 Bigdeli AK, Gazyakan E, Schmidt VJ. et al. Long-term outcome after successful lower extremity free flap salvage. J Reconstr Microsurg 2019; 35 (04) 263-269