J Hand Microsurg
DOI: 10.1055/s-0043-1761226
Case Report

A Unique Case of Venous Coupler Disruption and Salvage of Venous Anastomosis in a Case of Free Latissimus Dorsi Flap Reconstruction

Ansarul Haq
1   Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Patna, Bihar, India
,
Veena Singh
1   Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Patna, Bihar, India
,
1   Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Patna, Bihar, India
,
Amarjeet Kumar
2   Department of Anesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India
,
Anupama Kumari
1   Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Patna, Bihar, India
› Author Affiliations
Funding None.

Abstract

Free flaps are considered the gold standard for the reconstruction of various defects. Microvascular anastomosis is a very critical component of free flap surgery determining its success. The workhorse technique of hand suturing for microvascular anastomosis has consistently been used with excellent results. Recently, venous couplers are being increasingly used for performing venous anastomosis. We describe the case of a 14-year-old girl in which heel reconstruction was planned for an unstable scar and chronic osteomyelitis of the calcaneal region with a free latissimus dorsi muscle flap. Arterial anastomosis was done by hand suturing, while venous coupler (GEM coupler, Synovis Micro Companies Alliance) was used for venous anastomosis. Just before wound closure, the venous coupler spontaneously snapped open, resulting in disruption of the device and opening of the anastomosis. After securing hemostasis, the ring of the coupling device was tried to be removed, but it was adhered to the tunica externa due to the interlocking pins. Cutting the veins proximal to the rings would result in shortening of the vein with the requirement of a vein graft. The harvested latissimus dorsi muscle had a single vena comitans which had to be salvaged, so we improvised by everting the vein edges from the interlocking pins and completing the anastomosis by hand after freshening the margins. The interlocking rings were left as such in their place. Postoperative period was uneventful, and the flap survived with good results. Thus, this is a unique case where we report for the first time the disruption of a venous coupling device and subsequent salvage of free flap.



Publication History

Article published online:
13 March 2023

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  • References

  • 1 Jacobson JI, Suarea EL. Microsurgery in anastomosis of small vessels. Surg Forum 1960; 11: 243-245 . Accessed on January 17, 2023, at: https://api.semanticscholar.org/CorpusID:54156528
  • 2 Gardiner MD, Nanchahal J. Strategies to ensure success of microvascular free tissue transfer. J Plast Reconstr Aesthet Surg 2010; 63 (09) e665-e673
  • 3 Pohlenz P, Klatt J, Schön G, Blessmann M, Li L, Schmelzle R. Microvascular free flaps in head and neck surgery: complications and outcome of 1000 flaps. Int J Oral Maxillofac Implants 2012; 41 (06) 739-743
  • 4 Gilbert RW, Ragnarsson R, Berggren A, Östrup L. Strength of microvascular anastomoses: comparison between the unilink anastomotic system and sutures. Microsurgery 1989; 10 (01) 40-46
  • 5 Nakayama K, Yamamoto K, Tamiya T. A new simple apparatus for anastomosis of small vessels. Preliminary report. J Int Coll Surg 1962; 38: 12-26
  • 6 Ostrup LT, Berggren A. The UNILINK instrument system for fast and safe microvascular anastomosis. Ann Plast Surg 1986; 17 (06) 521-525
  • 7 Kind GM, Buncke GM, Buncke HJ. Foreign-body sensation following 3M coupler use in the hand. Ann Plast Surg 1996; 37 (04) 418-421
  • 8 Hallock GG. The microanastomotic coupler masquerading as a foreign body. Plast Reconstr Surg 2008; 122 (05) 154e-155e
  • 9 Zomerlei TA, Komorowska-Timek E. Venous coupler migration: a near miss. Microsurgery 2014; 34 (04) 331-332
  • 10 Kubo T, Kitamura N, Onoda M, Maeda D, Matsuda K, Hosokawa K. Exposure of a microvascular anastomotic coupler in head and neck reconstruction: a case report. Eplasty 2014; 14: e18
  • 11 Imahiyerobo TA, Spector JA. Late extrusion of a venous microvascular coupling ring. J Reconstr Microsurg 2013; 29 (07) 493-494
  • 12 Zhu Z, Wang X, Huang J. et al. Mechanical versus hand-sewn venous anastomoses in free flap reconstruction: a systematic review and meta-analysis. Plast Reconstr Surg 2018; 141 (05) 1272-1281
  • 13 Grewal AS, Erovic B, Strumas N, Enepekides DJ, Higgins KM. The utility of the microvascular anastomotic coupler in free tissue transfer. Can J Plast Surg 2012; 20 (02) 98-102
  • 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