Comparison of Outcomes of End-to-End versus End-to-Side Anastomoses in Lower Extremity Free Flap Reconstructions
17 August 2019
05 January 2020
29 March 2020 (online)
Background Whether to perform an end-to-end (ETE) versus end-to-side (ETS) arterial anastomosis is an integral part of preoperative planning and intraoperative decision making in free flap-based reconstructions. This study evaluated the impact of microsurgical anastomotic technique on outcomes of lower extremity reconstructions, with a focus on patients with peripheral arterial disease (PAD).
Methods Over a 6-year period, 425 patients underwent 437 microvascular lower extremity free flap reconstructions with fasciocutaneous anterolateral thigh- or gracilis muscle flaps at a single surgical center. The cases were divided into an ETE (n = 297 patients) versus ETS (n = 128 patients) group according to the anastomotic technique. A retrospective analysis of patients' demographics, perioperative details, surgical complications, free flap types, recipient sites, flap survival, and the potential impact of PAD on outcomes was performed. Patient groups were comparable regarding comorbidities, American Society of Anesthesiologists scores, types of performed free flaps and recipient sites.
Results We found no significant differences between the ETE versus ETS groups regarding the rate of major or minor complications (p > 0.05). Specifically, in patients suffering from PAD (n = 64) the type of arterial anastomosis had no effect on the outcome.
Conclusion Overall, no significant differences in outcomes were observed when comparing the types of performed arterial anastomosis. This observation also held true for the subgroup of patients with PAD. Given that an ETS anastomosis did not increase the risk to encounter complications while preserving distal perfusion, we believe that this technique is the method of choice, especially in patients with impaired vascular status.
* These authors contributed equally to this work.
- 1 Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg 1998; 102 (03) 599-616 , discussion 617–618
- 2 Attinger CE, Evans KK, Bulan E, Blume P, Cooper P. Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plast Reconstr Surg 2006; 117 (7, suppl): 261S-293S
- 3 Heidekrueger PI, Ninkovic M, Heine-Geldern A, Herter F, Broer PN. End-to-end versus end-to-side anastomoses in free flap reconstruction: single centre experiences. J Plast Surg Hand Surg 2017; 51 (05) 362-365
- 4 Godina M. Preferential use of end-to-side arterial anastomoses in free flap transfers. Plast Reconstr Surg 1979; 64 (05) 673-682
- 5 Samaha FJ, Oliva A, Buncke GM, Buncke HJ, Siko PP. A clinical study of end-to-end versus end-to-side techniques for microvascular anastomosis. Plast Reconstr Surg 1997; 99 (04) 1109-1111
- 6 Tsai YT, Lin TS. The suitability of end-to-side microvascular anastomosis in free flap transfer for limb reconstruction. Ann Plast Surg 2012; 68 (02) 171-174
- 7 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
- 8 Zhang L, Moskovitz M, Piscatelli S, Longaker MT, Siebert JW. Hemodynamic study of different angled end-to-side anastomoses. Microsurgery 1995; 16 (02) 114-117
- 9 Daigeler A, Kneser U, Fansa H, Riester T, Uder M, Horch RE. ; Deutschsprachige Gemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße. Reconstruction of the vascular compromised lower extremity—report of the consensus workshop at the 35. Meeting of the DAM (Deutschsprachige Gemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße) 2013 in Deidesheim [in German]. Handchir Mikrochir Plast Chir 2014; 46 (04) 248-255
- 10 Pu LL. A comprehensive approach to lower extremity free-tissue transfer. Plast Reconstr Surg Glob Open 2017; 5 (02) e1228
- 11 Fischer JP, Wink JD, Nelson JA. , et al. A retrospective review of outcomes and flap selection in free tissue transfers for complex lower extremity reconstruction. J Reconstr Microsurg 2013; 29 (06) 407-416
- 12 Koul AR, Patil RK, Nahar S. Unfavourable results in free tissue transfer. Indian J Plast Surg 2013; 46 (02) 247-255
- 13 Cho EH, Garcia RM, Blau J. , et al. Microvascular anastomoses using end-to-end versus end-to-side technique in lower extremity free tissue transfer. J Reconstr Microsurg 2016; 32 (02) 114-120
- 14 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
- 15 Criqui MH, Aboyans V. Epidemiology of peripheral artery disease. Circ Res 2015; 116 (09) 1509-1526
- 16 Oh TS, Lee HS, Hong JP. Diabetic foot reconstruction using free flaps increases 5-year-survival rate. J Plast Reconstr Aesthet Surg 2013; 66 (02) 243-250
- 17 Hong JP, Oh TS. An algorithm for limb salvage for diabetic foot ulcers. Clin Plast Surg 2012; 39 (03) 341-352
- 18 Salvo NL, Walsh MD, Brewster LP. Promoting limb salvage through multi-disciplinary care of the diabetic patient. Curr Treat Options Cardiovasc Med 2017; 19 (07) 55
- 19 Kneser U, Arkudas A, Beier JP. , et al. Extended skin and soft tissue defects after vascular wounds: plastic surgical concepts [in German]. Zentralbl Chir 2013; 138 (05) 536-542
- 20 Czerny M, Trubel W, Zimpfer D. , et al. Limb-salvage by femoro-distal bypass and free muscle flap transfer. Eur J Vasc Endovasc Surg 2004; 27 (06) 635-639
- 21 Haddock NT, Weichman KE, Reformat DD, Kligman BE, Levine JP, Saadeh PB. Lower extremity arterial injury patterns and reconstructive outcomes in patients with severe lower extremity trauma: a 26-year review. J Am Coll Surg 2010; 210 (01) 66-72
- 22 Chou C, Kuo PJ, Chen YC. , et al. Combination of vascular intervention surgery and free tissue transfer for critical diabetic limb salvage. Ann Plast Surg 2016; 77 (suppl 1): S16-S21
- 23 Seth AK, Iorio ML. Super-thin and suprafascial anterolateral thigh perforator flaps for extremity reconstruction. J Reconstr Microsurg 2017; 33 (07) 466-473
- 24 Cho EH, Shammas RL, Carney MJ. , et al. Muscle versus fasciocutaneous free flaps in lower extremity traumatic reconstruction: a multicenter outcomes analysis. Plast Reconstr Surg 2018; 141 (01) 191-199
- 25 Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109 (07) 2219-2226 , discussion 2227–2230
- 26 Franco MJ, Nicoson MC, Parikh RP, Tung TH. Lower extremity reconstruction with free gracilis flaps. J Reconstr Microsurg 2017; 33 (03) 218-224
- 27 Zachara M, Drozdowski P, Wysocki M, Siewiera I, Wójcicki P. Anatomical variability of the anterolateral thigh flap perforators between sexes: a cadaveric study. Eur J Plast Surg 2013; 36 (03) 179-184
- 28 Magden O, Tayfur V, Edizer M, Atabey A. Anatomy of gracilis muscle flap. J Craniofac Surg 2010; 21 (06) 1948-1950
- 29 Park S, Han SH, Lee TJ. Algorithm for recipient vessel selection in free tissue transfer to the lower extremity. Plast Reconstr Surg 1999; 103 (07) 1937-1948