Principles of Microvascular Surgery.

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The no-reflow effect • Zdeblick, J Hand Surg 1985 - no-reflow in rat hind limbs. » Predictors - • RBC aggregates 5min after replantation. • Tissue pH change persisting for 1h or more postreplantation. » Mechanism - • Ongoing arterial obstruction. • AV shunting. • Altered thrombogenic / fibrinolitic system. • Jacobs, PRS 1981 - The no-reflow effect » relationship between warm ischemia time and fibrinolitic activity. » Greatest drop in fibrinolysis - 0-6h of warm ischemia. • Suval, J Surg Res 1987 - » Changes in microvascular permeability in reperfusion after 30min or 2h of ischemia. » First manifestation of tissue damage in reperfusion injury - d/t leukocytic and endothelial cell interaction. » The no-reflow - in 30% of muscle tissue regardless of ischemia time. 24
• Treatment - The no-reflow effect » Reports of flaps salvage with thrombolytic drugs. » Nonsteroidal antiinflamatory agents - inhibit cyclooxygenase - blocks thromboxane A2 (vasoconstriction and thrombus formation). • Douglas, PRS 1987 - ibuprofen treated flaps survive longer periods of ischemia. • Accelerated fluorescein uptake - reversal of thrombosis and vasoconstriction. Flap failure - summary • Endothelial disruption. • Exposure of subendothelial collagen. • Platelet adherence and aggregation. • When critical mass - trigger of fibrin deposition. • Vasospasm. • Stenosis. • Thrombosis of the vessel. • Blood flow falls. • When critical level - flap failure. 25
Page 1 and 2: Principles of Microvascular Surgery
Page 3 and 4: History • Malt & McKhann, 1962 -
Page 5 and 6: History • Danil & Taylor + O’br
Page 7 and 8: Basic Science Concepts in Microsurg
Page 9 and 10: Vessel Injury and Regeneration •
Page 11 and 12: Vessel Wall Healing • At the time
Page 13 and 14: Damage from needles, sutures and te
Page 15 and 16: The clotting mechanism • Platelet
Page 17 and 18: Antithrombotic therapy Heparin (con
Page 19 and 20: Antithrombotic therapy Low molecula
Page 21 and 22: Antithrombotic therapy conclusions:
Page 23: The no-reflow effect • Ames, Am J
Page 27 and 28: • Loupes… • Or microscope? Mi
Page 29 and 30: • Key sutures - Anastomotic techn
Page 31 and 32: End-to-end, end-to-side and end-in-
Page 33 and 34: Laser anastomosis • Various exper
Page 35 and 36: Monitoring perfusion • Doppler ul
Page 37 and 38: The influence of patient factors
Page 39 and 40: Free flaps • Twenty years ago - f
Page 41 and 42: • Free groin flap - Free flaps -
Page 43 and 44: Free flaps - fascia • Useful wher
Page 45 and 46: Free flaps - muscle • Free latiss
Page 47 and 48: Free fibula flap 47

Principles of Microvascular Surgery.

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