Floor plan - 2013 Annual Meeting - American Association for Hand ...

Chronic deep venous thrombosis in the peroneal veins of a fibula flap: strategies for salvage
and avoidance
Institution where the work was prepared: Brigham and Women's Hospital, Boston, MA, USA
Amir Taghinia, MD; Harvard Plastic Surgery; Julian J. Pribaz, MD; Brigham and Women's Hospital, Harvard Medical
School; Lifei Guo, MD, PhD; Brigham and Women's Hospital
Thrombosis of free flap vessels is usually a significant concern after micro-anastomosis; however, reports of chronic thrombotic venous
occlusion prior to free flap transfer are rare. We present a case of chronic occlusion of the peroneal veins of a free fibula osteocutaneous
flap and a successful salvage attempt. Prolonged bedrest from a contralateral ankle fracture led to deep venous thrombosis and chronic
occlusion in these veins. Successful flap transfer was possible by using a venous branch from the soleus muscle for microanastomosis.
An extensive literature search of 773 cases yielded only one similar example. Discussion with multiple experienced microsurgeons
yielded another anecdotal case. In both of these other cases, flap transfers had to be aborted. Based on our experience, we recommend
early intra-operative identification and preservation of the soleus vein branch in case of similar venous difficulties during free fibula
harvest. The use of pre-operative ultrasound to assess these veins in selected patients with history of lower extremity trauma is also
recommended prior to flap harvest.
Go for the Jugular – A 10-year Experience with End-to-Side Anastomosis to the Internal
Jugular Vein in 320 Head and Neck Free Flaps
Institution where the work was prepared: Memorial Sloan-Kettering Cancer Center, New York, NY, USA
Eric Halvorson, MD; University of North Carolina; Peter G. Cordeiro; Memorial Sloan-Kettering Cancer Center
INTRODUCTION:
Venous patency is critical for successful free tissue transfer in head and neck reconstruction. Although multiple suitable arteries are often
found, venous recipients are usually limited to the internal jugular vein, stumps of its branches, and/or the external jugular vein. We have
found that preferential use of end-to-side anastomosis to the internal jugular vein whenever possible offers distinct advantages, and
has consistently yielded excellent outcomes. A 10-year experience with 320 cases is presented.
METHODS:
A prospectively maintained database was queried for patients who underwent free flap reconstruction of head and neck oncologic
defects from 1996 to 2006 by the senior author. Intravenous heparin was given prior to flap harvest, and aspirin was administered for 5
days post-operatively. End-to-side venous anastomosis was performed with 9-0 nylon continuous suture. Patient demographics, donor
and recipient sites, and complications were noted for all patients who underwent end-to-side anastomosis to the internal jugular vein.
RESULTS:
Over a 10-year period, a total of 470 patients underwent head and neck reconstruction with free tissue transfer, of which 320 (70%)
underwent end-to-side anastomosis to the internal jugular vein. Mean patient age in this group was 56 years (range 7-88). The most
common flaps employed were the rectus (33%), forearm (28%), and fibula (21%) flaps. The most common recipient sites were the
mandible with or without floor of mouth (27%), pharyngoesophagus (25%), and tongue or cheek (17% each). Minor wound healing problems,
infection, hematoma, and death were noted in 5% or less. Partial flap loss was seen in 2%. Total flap loss, arterial thrombosis, and
venous thrombosis all occurred in less than 1% of patients.
CONCLUSION:
Presented is a large series of consecutive cases by a single surgeon at one institution over a 10-year period, with preferential use of endto-side
anastomosis to the internal jugular vein for head and neck free flap reconstruction. Excellent outcomes were noted, which compare
favorably with other described techniques. The size, constant anatomy, availability, patency, and possibility for multiple anastomoses
of any size at any site along its course in the neck make use of the IJV very advantageous. End-to-side anastomosis to the IJV in
this situation results in high patency rates, and kinking is not observed when the neck is rotated. Theoretical advantages include
increased flow in the IJV (which may promote venous outflow and wash away microthrombi) due to its size and the respiratory venous
pump.
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