Single Artery Upper Extremity Salvage with Two Free Flap End-to-Side Brachial Artery Anastomoses

Abstract

Background A 36-year-old male was involved in a motor vehicle accident, presenting with a Guistillo's IIIB crush injury to the upper extremity. A severely comminuted ulnar fracture resulted in a 10-cm bone defect with significant overlying soft tissue injury.

Methods The injury resulted in a wide zone of injury with inadequate collateral vascularity at the level of the elbow and distal viability dependent on the brachial artery. An osteocutaneous free fibular flap and fasciocutaneous anterolateral thigh flap were used to reconstruct the defect with both flaps anastomosed in an end-to-side fashion to the brachial artery.

Results The upper extremity was successfully salvaged, and the patient discharged from hospital at postoperative day 10. Both free flaps survived with no donor or recipient site complications at a follow-up period of 2 years.

Conclusion The case illustrates the challenges inherent to significant Guistillo's IIIB injuries with insufficient recipient vessels over a large zone of injury. While performing anastomoses outside the zone of injury is preferred, this case demonstrates the success of performing multiple anastomoses to the brachial artery in an end-to-side fashion within the zone of injury.

Keywords

trauma - upper extremity reconstruction - end to side anastomosis

Note

Written informed consent was obtained from the patient for publication of clinical details and clinical images. A copy of the consent form is available for review with the editor of the journal.

Authors' Contributions

M.J.S. and J.Z. were involved in both writing and editing the manuscript.

Publication History

Received: 03 May 2020

Accepted: 09 July 2020

Article published online:
06 September 2020

• References

• 1 Culliford IV AT, Spector J, Blank A, Karp NS, Kasabian A, Levine JP. The fate of lower extremities with failed free flaps: a single institution's experience over 25 years. Ann Plast Surg 2007; 59 (01) 18-21 , discussion 21–22
• 2 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
• 3 Lee ZH, Stranix JT, Rifkin WJ. , et al. Timing of microsurgical reconstruction in lower extremity trauma: an update of the Godina paradigm. Plast Reconstr Surg 2019; 144 (03) 759-767
• 4 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
• 5 Kumar AR, Grewal NS, Chung TL, Bradley JP. Lessons from the modern battlefield: successful upper extremity injury reconstruction in the subacute period. J Trauma 2009; 67 (04) 752-757
• 6 Rifkin WJ, Stranix JT, Borab ZM. , et al. Abstract 142: timing of traumatic lower extremity free flap reconstruction: does time to coverage impact outcomes?. Plast Reconstr Surg Glob Open 2018; 6 (4, suppl): 111-112
• 7 Abdou SA, Stranix JT, Daar DA. , et al. Free tissue transfer with distraction osteogenesis and Masquelet technique is effective for limb salvage in patients with Gustilo type IIIB open fractures. Plast Reconstr Surg 2020; 145 (04) 1071-1076
• 8 Malizos KN, Zalavras CG, Soucacos PN, Beris AE, Urbaniak JR. Free vascularized fibular grafts for reconstruction of skeletal defects. J Am Acad Orthop Surg 2004; 12 (05) 360-369
• 9 Beris AE, Lykissas MG, Korompilias AV. , et al. Vascularized fibula transfer for lower limb reconstruction. Microsurgery 2011; 31 (03) 205-211
• 10 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
• 11 Duymaz A, Karabekmez FE, Vrtiska TJ, Mardini S, Moran SL. Free tissue transfer for lower extremity reconstruction: a study of the role of computed angiography in the planning of free tissue transfer in the posttraumatic setting. Plast Reconstr Surg 2009; 124 (02) 523-529
• 12 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
• 13 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
• 14 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
• 15 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
• 16 Stranix JT, Borab ZM, Rifkin WJ. , et al. Proximal versus Distal Recipient Vessels in Lower Extremity Reconstruction: A Retrospective Series and Systematic Review. J Reconstr Microsurg 2018; 34 (05) 334-340
• 17 Spector JA, Levine S, Levine JP. Free tissue transfer to the lower extremity distal to the zone of injury: indications and outcomes over a 25-year experience. Plast Reconstr Surg 2007; 120 (04) 952-959
• 18 Stranix JT, Lee ZH, Anzai L. , et al. Optimizing venous outflow in reconstruction of Gustilo IIIB lower extremity traumas with soft tissue free flap coverage: Are two veins better than one?. Microsurgery 2018; 38 (07) 745-751
• 19 Adams Jr WP, Ansari MS, Hay MT. , et al. Patency of different arterial and venous end-to-side microanastomosis techniques in a rat model. Plast Reconstr Surg 2000; 105 (01) 156-161
• 20 Verhelle NA, Heymans O. How to deal with difficult microsurgical end-to-side anastomoses. Microsurgery 2005; 25 (03) 203-208
• 21 Dotson RJ, Bishop AT, Wood MB, Schroeder A. End-to-end versus end-to-side arterial anastomosis patency in microvascular surgery. Microsurgery 1998; 18 (02) 125-128