Download PDF
J Reconstr Microsurg 2023; 39(06): 482-492
DOI: 10.1055/s-0042-1760109
Original Article

Association of Dual Venous Anastomosis with Reduced Risks for Flap Congestion in Microsurgical Lower Extremity Reconstruction: A Multicenter Study

Sang-Hun Lee
1   Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
,
Kyeong-Tae Lee   *
1   Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
,
Bo Young Park   *
2   Department of Plastic and Reconstructive Surgery, School of Medicine, Ewha Womans University, Seoul, Republic of Korea
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

Background Flap congestion related with venous thrombosis is a major cause for microsurgical lower extremity reconstruction failure. Conducting dual venous anastomosis has been suggested to reduce risks for the adverse outcomes; however, its efficacy remains controversial. This study evaluated a potential association of dual venous anastomosis with the development of flap congestion in diverse clinical situations.

Methods This multicenter study included patients who underwent microsurgical lower extremity reconstruction at two institutions. They were divided into two groups based on the number of venous anastomoses—single and dual groups. Their perfusion-related complications (PRCs), including total/partial flap loss, arterial or venous insufficiency, and emergent reoperation, were compared. Independent association of the number of venous anastomoses with the outcomes was evaluated. Further analyses were conducted using propensity score matching.

Results In total, 225 cases were analyzed, of which 92 were included in the single group and the other 133 in the dual group. The two groups had generally similar baseline characteristics. The dual group presented significantly lower rates of PRC, including total/partial flap loss, flap congestion, and emergent reoperation. Multivariable analyses showed that conducting dual venous anastomoses was associated with reduced risks for the development of overall PRC and flap congestion. These associations were more prominent when restricting analyses for cases with chronic wound and trauma (vs. oncologic defects). Similar associations were observed in the propensity score matching analysis.

Conclusion Conducting dual venous anastomosis seems associated with reduced risks for flap congestion in microsurgical lower extremity reconstruction, especially for cases with unfavorable conditions.

Keywords

lower extremity reconstruction - dual venous anastomosis - congestion

* These two authors are co-corresponding authors.




Publication History

Received: 19 April 2022

Accepted: 31 October 2022

Article published online:
29 December 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Xu Z, Zhao XP, Yan TL. et al. A 10-year retrospective study of free anterolateral thigh flap application in 872 head and neck tumour cases. Int J Oral Maxillofac Implants 2015; 44 (09) 1088-1094
    CrossrefPubMedGoogle Scholar
  • 2 Acosta R, Smit JM, Audolfsson T. et al. A clinical review of 9 years of free perforator flap breast reconstructions: an analysis of 675 flaps and the influence of new techniques on clinical practice. J Reconstr Microsurg 2011; 27 (02) 91-98
    Article in Thieme ConnectPubMedGoogle Scholar
  • 3 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
    CrossrefPubMedGoogle Scholar
  • 4 Song CT, Koh K, Tan BK, Goh T. Free-flap lower extremity reconstruction: a cohort study and meta-analysis of flap anastomotic outcomes between perforator and nonperforator flaps. J Reconstr Microsurg 2018; 34 (06) 455-464
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Riot S, Herlin C, Mojallal A. et al. A systematic review and meta-analysis of double venous anastomosis in free flaps. Plast Reconstr Surg 2015; 136 (06) 1299-1311
    CrossrefPubMedGoogle Scholar
  • 6 Lee YC, Chen WC, Chen SH. et al. One versus two venous anastomoses in anterolateral thigh flap reconstruction after oral cancer ablation. Plast Reconstr Surg 2016; 138 (02) 481-489
    CrossrefPubMedGoogle Scholar
  • 7 Chaput B, Vergez S, Somda S. et al. Comparison of single and double venous anastomoses in head and neck oncologic reconstruction using free flaps: a meta-analysis. Plast Reconstr Surg 2016; 137 (05) 1583-1594
    CrossrefPubMedGoogle Scholar
  • 8 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
    CrossrefPubMedGoogle Scholar
  • 9 Stranix JT, Anzai L, Mirrer J. et al. Dual venous outflow improves lower extremity trauma free flap reconstructions. J Surg Res 2016; 202 (02) 235-238
    CrossrefPubMedGoogle Scholar
  • 10 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
    CrossrefPubMedGoogle Scholar
  • 11 Mattos D, Diamond S, Chattha AS, Riesel JN, Iorio ML. Venous anastomoses in anterolateral thigh flaps for the lower extremity: vessel selection in lieu of obligatory number. Ann Plast Surg 2018
    PubMedGoogle Scholar
  • 12 Lorenzo AR, Lin CH, Lin CH. et al. Selection of the recipient vein in microvascular flap reconstruction of the lower extremity: analysis of 362 free-tissue transfers. J Plast Reconstr Aesthet Surg 2011; 64 (05) 649-655
    CrossrefPubMedGoogle Scholar
  • 13 Iamaguchi R, Burgos F, Silva G. et al. Do two venous anastomoses decrease venous thrombosis during limb reconstruction?. Clin Hemorheol Microcirc 2019; 72 (03) 269-277
    CrossrefPubMedGoogle Scholar
  • 14 Heidekrueger PI, Ehrl D, Heine-Geldern A, Ninkovic M, Broer PN. One versus two venous anastomoses in microvascular lower extremity reconstruction using gracilis muscle or anterolateral thigh flaps. Injury 2016; 47 (12) 2828-2832
    CrossrefPubMedGoogle Scholar
  • 15 Dodd SX, Morzycki A, Nickel KJ, Campbell S, Guilfoyle R. One or two venous pedicles by anastomoses for free flaps in reconstruction of the lower extremity: a systematic review and meta-analysis. Microsurgery 2021; 41 (08) 792-801
    CrossrefPubMedGoogle Scholar
  • 16 Forner D, Williams BA, Makki FM, Trites JR, Taylor SM, Hart RD. Late free flap failure in head and neck reconstruction: a systematic review. Ear Nose Throat J 2018; 97 (07) 213-216
    CrossrefPubMedGoogle Scholar
  • 17 Wax MK, Rosenthal E. Etiology of late free flap failures occurring after hospital discharge. Laryngoscope 2007; 117 (11) 1961-1963
    CrossrefPubMedGoogle Scholar
  • 18 Kim SY, Lee KT, Mun GH. Postoperative venous insufficiency in microsurgical lower extremity reconstruction and deep vein thrombosis potential as assessed by a Caprini risk assessment model. Plast Reconstr Surg 2015; 136 (05) 1094-1102
    CrossrefPubMedGoogle Scholar
  • 19 Abdelfattah U, Power HA, Song S, Min K, Suh HP, Hong JP. Algorithm for free perforator flap selection in lower extremity reconstruction based on 563 cases. Plast Reconstr Surg 2019; 144 (05) 1202-1213
    CrossrefPubMedGoogle Scholar
  • 20 Karadsheh MJ, Shafqat MS, Krupp JC, Weiss ES, Patel SA. A theoretical model describing the dynamics of venous flow in the DIEP flap. J Reconstr Microsurg 2019; 35 (09) 688-694
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Pignatti M, Pinto V, Giorgini FA. et al. Different hydraulic constructs to optimize the venous drainage of DIEP flaps in breast reconstruction: decisional algorithm and review of the literature. J Reconstr Microsurg 2021; 37 (03) 216-226
    Article in Thieme ConnectPubMedGoogle Scholar
  • 22 Hanasono MM, Kocak E, Ogunleye O, Hartley CJ, Miller MJ. One versus two venous anastomoses in microvascular free flap surgery. Plast Reconstr Surg 2010; 126 (05) 1548-1557
    CrossrefPubMedGoogle Scholar