Macrovascular Surgery and the Microsurgeon

ABSTRACT

The improvement of success rates in microsurgery can be attributed as much to better technical skills, as to the more frequent selection of donor or recipient sites with consistent, larger-caliber vessels. Often, these vessels may be larger than major limb source vessels, and anastomoses using loupes can then be successful, even without requiring an operating microscope. Thus, distinguishing our capabilities from the domain of the general vascular surgeon, who traditionally deals only with the ravages of disease or trauma to such large vessels, has become blurred. For some free-tissue transfers, and especially limb replantations, perhaps it would be appropriate for the microsurgeon sometimes to enter the realm of the macrovascular surgeon for enhancement of the overall outcome.

A review of our 202 free flaps and pediatric limb revascularizations has validated this opinion, as significant portions in 19 of these cases required unequivocal macrovascular surgery. These included vein-graft bypasses (9) of major segmental arterial defects of limbs (that incidentally improved collateral circulation, although intended primarily to simplify arterial inflow to a free flap simultaneously needed to cover a concomitant soft-tissue defect). Similarly, arterial grafts as part of a “flow-through” free flap (3) were used for immediate coverage and concurrent limb revascularization. Finally, two toddlers who sustained disruption of named leg vessels had microsurgical repair after referral from the vascular service; they believed we were better able to deal with such diminutive vasculature. These observations are not intended as evidence that vascular surgery may be better performed by the microsurgeon; rather, that the best results of microsurgery often will incorporate technical aspects usually considered as macrovascular surgery.