The internal oblique-iliac crest osseomyocutaneous microvascular free flap in head and neck reconstruction

The iliac crest osseocutaneous free flap, based on the deep circumflex iliac artery and vein, was a landmark contribution to head and neck reconstruction. Two major problems associated with this flap are the lack of flexibility in placement of the skin paddle with relation to the bone graft, and the excessive thickness of the skin paddle when used in the oral cavity. The scapular osseocutaneous flap has achieved recent popularity for mandibular reconstruction based, in part, on its thin skin paddle that is easily positioned in three dimensions with relation to the bone graft. However, the segment of bone that can be harvested from the iliac crest is superior to that of the lateral border of the scapula because of its increased length, thickness, and natural contour. In 1984 the internal oblique free muscle flap based on the ascending branch of the deep circumflex iliac artery was described for use in reconstruction of the extremities only. The authors introduce the application of the internal oblique-iliac crest osseomyocutaneous free flap for mandibular reconstruction. The mobility of the internal oblique muscle with relation to the iliac bone graft has permitted its use for inner mucosal defects or outer cutaneous defects when covered with a skin graft. Following denervation atrophy, the muscle component becomes a thin, pliable piece of tissue that easily conforms to three-dimensional defects of the head and neck. This increased flexibility, the established benefits of the iliac bone, and the ease of intraoperative positioning for a two-team approach make this composite flap an outstanding tool for mandibular reconstruction. Two representative cases and a detailed description of flap harvesting, insetting, and donor-site closure are presented.

Primary placement of osseointegrated implants in microvascular mandibular reconstruction

The goal of mandibular reconstruction is to rehabilitate the patient by restoring occlusal relationships, lower facial contour, oral continence, and a denture-bearing surface. One of the major advantages of the use of vascularized bone over all other methods of mandibular reconstruction is its ability to achieve dental rehabilitation rapidly. The use of osseointegrated dental implants is a valuable adjunct in oral rehabilitation. It provides the most rigid form of stabilization to withstand the forces of mastication. In situations in which soft tissue reconstruction or the height of the alveolar ridge is not sufficient for a tissue-borne denture, implants offer the most suitable alternative. Mandibular reconstruction with free tissue transfer techniques is ideally suited for the placement of implants. These can be inserted at the time of mandibular reconstruction. Four months after surgery, when the integration process has occurred, the implants are unroofed, loaded, and ready for prosthetic placement. We will present several representative patients who underwent mandibular reconstruction with microvascular free bone transfer who have been successfully rehabilitated by osseointegrated implants. The process of osseointegration, different types of dental implants, and issues regarding radiation and implants are discussed. This is the first report of dental rehabilitation by primary placement of dental implants in patients undergoing microvascular mandibular reconstruction.

The internal oblique-iliac crest osseomyocutaneous free flap in oromandibular reconstruction. Report of 20 cases

Microvascular free tissue transfer techniques using composite flaps are the most reliable method for the combined bone and soft-tissue reconstitution of oromandibular defects. Functional oromandibular reconstruction requires that maximum tongue mobility be achieved along with dental prosthetic rehabilitation. The internal oblique-iliac crest osseomyocutaneous microvascular free flap was used in 20 patients for oromandibular reconstruction. The internal oblique muscle, based on the ascending branches of the deep circumflex iliac artery and vein, was used to resurface mucosal defects of the oral cavity and pharynx. The iliac bone, because of its length, width, and natural contour, is the best source of vascularized bone for mandibular reconstruction. The improved soft-tissue component of this composite flap markedly improved the functional results. Reconstruction failed in one patient. Eleven patients underwent dental rehabilitation with either a tissue-borne or osseointegrated implant-borne denture. Follow-up of longer than one year showed minimal donor site morbidity.

Venous thrombosis: the clinical problem

Although the exact cause of DVT is not known, venous thrombosis and its sequelae remain important clinical problems. Pulmonary embolism is a significant cause of morbidity and mortality in the hospitalized population, and the postthrombotic syndrome affects a large portion of the general population. While specific screening tests are not readily available to detect those patients who are likely to develop DVT, certain clinical risk factors have been identified that predispose to thrombosis. These groups include patients undergoing a wide variety of surgical procedures, patients with cardiac disease or cancer, pregnant or postpartum women, and individuals with previous history of DVT. The diagnosis of thrombosis is based on clinical findings and must be confirmed with appropriate laboratory tests. While contrast venography remains the gold standard, noninvasive tests have become increasingly more accurate. The recent use of real-time B-mode ultrasonic imaging and duplex sonography for the diagnoses of DVT has been shown to be efficacious. The postthrombotic syndrome with its associated chronic pain and ulcerations remains a significant clinical problem. The general diagnosis of this condition is readily made on clinical grounds in the advanced state. However, exact knowledge of the location and cause of the venous pathology can only be obtained using objective diagnostic tests. Older noninvasive and invasive tests may diagnose the presence of venous obstruction, valvular incompetence, and also may document venous hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)

Origin of deep vein thrombi in an ambulatory population

Eighty symptomatic ambulatory outpatients with acute deep vein thrombosis were evaluated with ascending contrast venography and ultrasonic imaging to determine the origin and distribution of thrombosis and to analyze clinical risk factors. Isolated calf vein thrombosis was present in 42.5 percent of the limbs, combined calf and proximal deep vein thrombosis in 47.5 percent, and isolated proximal thrombosis in 10 percent of the limbs. Discontinuity of thrombus was present in 55 percent, whereas 45 percent exhibited a continuous column of thrombus. The results of this study indicate that in the ambulatory outpatient population, acute deep vein thrombosis begins segmentally in the calf and proximal vessels and frequently coalesces into a continuous column of thrombus over several days. We believe that all cases of acute deep vein thrombosis should be treated and patients with evidence of previous acute deep vein thrombosis should be closely monitored for possible recurrences.

The use of split-thickness skin as an autogenous arterial conduit

Eight mongrel dogs were anesthetized using general anesthesia, and graft consisting of split-thickness skin obtained from their abdomen was devised and inserted in each of their infrarenal aortas. Six of the grafts were reinforced with meshed polytetrafluoroethylene (PTFE) as an outer layer to prevent potential aneurysmal dilatation of the skin graft. None of the dogs received aspirin at any time. The dogs were sacrificed at one, four, and six weeks. The grafts were examined with light microscopy and three of them were analyzed with scanning electron microscope. All grafts remained patent and none formed aneurysmal dilatations. None of the dogs developed infections or aortoenteric fistulas. Of the three grafts that showed thrombus-free areas, all were oriented with the epidermis facing the lumen. The three grafts where the epidermis formed the external surface did not degenerate in any area. Endothelium-like cells continuous with the host vessel were present on all grafts at 4 and 6 weeks by light or scanning electron microscopy. Preliminary data from this study indicated that split-thickness skin may be a suitable arterial conduit. Even if it does not prove to have long-term patency rates, it may be a suitable temporary conduit until infections resolve and synthetic prostheses can be reinserted.

The association of central retinal artery occlusion and extracranial carotid artery disease

To determine the incidence of associated carotid artery disease and the effect of carotid endarterectomy on subsequent neurologic sequelae, a retrospective study of 66 patients with central retinal artery occlusion (CRAO) was undertaken. Ipsilateral extracranial carotid artery disease was present in 23 of 33 patients (70%) who had carotid arteriography. Sixteen patients had carotid endarterectomy following their CRAO (Group I) and 50 did not (Group II). Seven of the 40 patients available for follow-up in Group II had a subsequent stroke (mean follow-up: 54 months). Of the seven Group II patients shown to have associated carotid disease (Group IIs), three (43%) had a subsequent stroke during follow-up (mean: 28.3 months) compared to zero in Group I (p = 0.033; mean follow-up: 18.7 months). Because of the strong association between CRAO and ipsilateral carotid artery disease and because of the significantly higher incidence of subsequent ipsilateral stroke in CRAO patients with carotid disease who did not undergo endarterectomy, thorough evaluation of the carotid arteries followed by carotid endarterectomy, if indicated, is warranted in CRAO patients who have no other obvious etiology for the occlusion.

Progress in the diagnosis of deep venous thrombosis: the efficacy of real-time B-mode ultrasonic imaging

Seventy-six limbs with clinically suspected acute deep venous thrombosis (DVT) were evaluated by means of ultrasonic imaging (UI) to define the ability of this technique to detect acute and chronic venous obstruction and to determine the origin and distribution of venous thrombi. UI was compared with ascending contrast phlebography in 46 limbs and was found to be 100% accurate in detecting both acute and chronic venous thrombosis. Overall, acute DVT was present in 63 of 76 limbs (83%) studied. Acute DVT was found in 24% and recurrent acute DVT in 76%. Our results indicate that although the calf veins are the most common site of involvement (89%), thrombi may frequently arise simultaneously in multiple anatomic sites. All limbs with recurrent acute DVT had evidence of previous calf thrombi but only 13% had previous proximal disease. This suggests that asymptomatic calf DVT is common and the prevalence of recurrent acute DVT is significantly greater than previously believed. We found UI is a practical, accurate, non-invasive method for investigating the pathogenesis of venous disease.

In situ tibial reconstruction. State-of-the-art or passing fancy

To further evaluate the efficacy of in situ saphenous vein bypass, the authors have reviewed their experience with in situ bypass. Between October 1981 and December 1985, 120 in situ saphenous vein bypass were performed; 81 were to infrapopliteal vessels. All procedures were performed for limb salvage. The mean patient age was 74 years, and 74% were men, 57% had diabetes mellitus, 92% were smokers, and 72% had hypertension and/or coronary artery disease. All patients were evaluated by preoperative noninvasive testing and biplanar angiography. All procedures were performed by the valve incision technique. The vein utilization rate was 91%. Grafts were routinely placed into isolated tibial segments and foot vessels without evidence of a patent pedal arch. Follow-up information was obtained at 3-month intervals. Patency and limb salvage data were calculated by life-table analysis. The cumulative patency rates were 98% at 1 month, 88% at 12 months, and 82% at 50 months. These data demonstrate that the in situ bypass maintains an excellent patency rate and provides durable limb salvage.

Popliteal-to-tibial in situ saphenous vein bypass for limb salvage in diabetic patients

This study has summarized our results with popliteal-tibial in situ saphenous vein bypass in 26 patients, 25 of whom were diabetic, over a 2 year period. Both above- and below-knee popliteal inflow sites were used for bypass of limb-threatening ischemia. Distal calf or pedal outflow sites were required in all but two patients who had sequential bypass performed to tibial sites. Postoperative ankle-brackial indices were calculated. Eleven patients had transcutaneous mapping surrounding the pedal skin envelope injuries. The mean lowest and highest transcutaneous oxygen values have been reported as a guide to successful healing.

Use of ultrasonic venography in the evaluation of venous valve function

Forty healthy limbs and 31 limbs with suspected deep venous insufficiency were imaged with real-time B-mode ultrasound to determine valve location, anatomic characteristics, and function. Valve function was evaluated by comparison with Doppler ultrasonographic techniques, and the data clearly indicated that ultrasonic venography accurately localized and determined the extent of deep venous reflux. Ascending contrast venography was performed in 15 postphlebitic limbs for assessment of valve location. The results indicate that ultrasonic venography is a more accurate method for visualization of valves in this group of patients. Therefore, ultrasonographic imaging is a valuable technique for evaluating limbs with chronic venous insufficiency.

B-mode ultrasonic imaging in the preoperative evaluation of saphenous vein

This prospective study was undertaken to determine if B-mode ultrasonic imaging of the greater saphenous vein can provide reliable information about anatomy, sites of valves, and location of major tributaries or duplicate systems. Preoperative ultrasonic imaging was performed on 15 consecutive patients prior to in situ saphenous bypass. The findings of the ultrasonic evaluations were compared with the intraoperative findings. Preoperative assessment of the greater saphenous vein was performed with a high resolution real-time B-mode ultrasonic imager. The procedure was performed with the patient seated with the leg extended. The saphenous vein was imaged starting at the ankle. A waterproof pen was used to mark the vein. The locations of valves and tributary vessels were marked and the diameter of the saphenous vein was recorded. These results were compared with operative findings. In all 15 patients, the saphenous vein was imaged. There was 100 per cent accuracy in the detection and location of valve sites. In one patient, the proximal portion of the vein was thrombosed and this was detected by the B-mode scan. There was exact correlation in 14 of 15 limbs (93%). The one error was due to the examiners' failure to identify a triple venous system; only a double venous system was identified by scan in this patient. The actual venous diameter was consistently within 0.5 mm of that measured by the ultrasound imager. In all patients, the ultrasound image demonstrated the correct anatomic location and size of the vein. In conclusion, B-mode ultrasonic imaging provides an accurate description of the anatomy of the saphenous vein, without the morbidity associated with contrast venography.

Intraoperative ultrasonic imaging of the carotid artery during carotid endarterectomy

Intraoperative real-time B-mode ultrasonography was used to evaluate the technical results of 155 carotid endarterectomies in 143 patients. Technical defects created as a result of the endarterectomy were detected in 43 of the 155 endarterectomies (27.7%) and included intimal flaps (73% of defects); strictures (18%); and arterial kinks, residual plaque, and intraluminal thrombi (9% collectively). Eleven of the 43 endarterectomy sites (7% of all endarterectomies) were reentered to correct a defect; none of these patients had neurologic deficits, which suggests that reentering an endarterectomy and correcting a defect does not, in and of itself, lead to a higher incidence of stroke. The incidence of stroke in patients with normal results of intraoperative ultrasonography was 3.8%, whereas the incidence of perioperative stroke in those patients with insignificant and thus uncorrected defects was 3.3%; this suggests that intraoperative ultrasonography is sufficiently sensitive to detect defects that, when left uncorrected, do not lead to a higher than usual incidence of stroke. Because intraoperative ultrasonography is safe and highly sensitive, we believe it is the method of choice for assessing the technical results of carotid endarterectomy.

Efficacy of femorofemoral bypass for intermittent claudication. Clinical and hemodynamic assessment

Twenty patients treated by femorofemoral bypass were retrospectively reviewed to determine if femorofemoral bypass was efficacious in the treatment of disabling claudication. The data have clearly demonstrated that two criteria are necessary for the successful outcome of femorofemoral bypass. First, the donor artery should be hemodynamically normal in order to support the recipient limb. This can be determined by either a normal treadmill exercise test result or by a normal preoperative intraarterial papaverine test result. Second, the patient's functional improvement will be dependent on the status of the runoff vessels in the recipient limb; therefore, many patients with patent superficial femoral and popliteal arteries will have excellent results (50 percent in this series), whereas those with occluded superficial femoral or popliteal arteries or both will have less improvement (40 percent in this series). Therefore, femorofemoral bypass should be used in the treatment of intermittent disabling claudication in the properly selected patient.

Results of arterial reconstruction of the foot

Sixty-five patients with critical ischemia required bypass to foot vessels. These procedures were performed by five different techniques: (1) femoral-foot bypass with in situ saphenous vein; (2) femoral-foot bypass with reversed autogenous saphenous vein; (3) femoral-foot bypass with polytetrafluoroethylene (PTFE); (4) popliteal-foot bypass with reversed autogenous saphenous vein; and (5) popliteal-foot bypass with PTFE. The two-year patency rate of femoral-foot bypass with in situ vein (96%) was significantly higher than femoral-foot bypass with reversed vein (42%), while both procedures demonstrated significantly higher patency than femoral-foot bypass with PTFE (0%). Popliteal-foot bypass with reversed vein (92%) was superior to both popliteal-foot bypass with PTFE (27%) and femoral-foot bypass with PTFE (0%). Femoral-foot bypass with in situ vein and popliteal-foot bypass with reversed vein have appreciably increased vein utilization, graft patency, and limb salvage.

Early experience with in situ saphenous vein bypass for distal arterial reconstruction

During a 36-month period 74 patients underwent infrainguinal in situ saphenous vein bypass to the popliteal or tibial vessels. The first 54 operations were performed with standard valvulotomes and valve-cutting scissors, while in the last 20 operations a new intraluminal valve-cutting device was used to incise the valves. Ninety-four percent of bypasses were performed for limb salvage, 80% of all operations were done to the tibial vessels, and 31% of bypasses were done to the ankle vessels. The operation was attempted in 81 patients and completed in 74 patients, for a vein utilization rate of 91%. Fifty-five percent of all veins had a distal diameter of less than 4 mm (average 3.6 mm). The patency rates were 92% at 3 months and 90% at 12 and 36 months for all grafts. There were six failed grafts, all within the first 6 months, and eight diabetic patients required reoperation, two for missed valve leaflets, and three needed revision of the distal anastomosis; however, all these grafts were patent at the time of reexploration. There were four perioperative deaths and two patients had nonfatal postoperative myocardial infarctions. This study demonstrates that in situ saphenous vein grafting provides for a high vein utilization rate and suggests that the technique provides for higher graft patency and limb salvage rates than do more traditional types of procedures.

Peripheral vascular trauma from close-range shotgun injuries

This report summarizes an eight-year experience (1976 to 1983) with 49 close-range shotgun blasts with associated major vascular injuries seen in a large urban hospital. Injuries to the upper extremity (40%), lower extremity (56%), and neck (4%) were seen. A high frequency of associated deep venous injury (82%), nerve injury (37%), fracture (33%), massive soft-tissue loss (43%), and compartmental hypertension (39%) was observed. There were no deaths in this series, and the limb salvage rate was 96%. Neither patient with multiple carotid artery injuries suffered a neurologic deficit. We attribute our success in the management of these complex injuries to rapid fracture immobilization, early and aggressive use of fasciotomy, adequate débridement of devitalized tissue, repair of deep venous injuries, arterial repair with autogenous tissue, and extra-anatomic bypass grafting in selected cases.

Ankle bypass: should we go the distance?

This report reviewed the results of 47 distal arterial reconstructions to or below the level of the malleolus. The operations were performed by the techniques of popliteal-to-distal bypass (20 procedures) and in situ bypass (27 procedures). Seventy-five percent of patients had gangrene of ischemic ulceration, and all procedures were performed for limb salvage. Seventy-three percent of all patients were diabetic. The patency rates for popliteal-to-distal bypass with reversed saphenous vein were 92 percent at 24 months and 57 percent at 60 months, with a limb salvage rate of 70 percent at 60 months; the patency rates for popliteal-to-distal bypass with PTFE were 53 percent at 12 months and 0 at 36 months, with a limb salvage rate of 53 percent at 36 months; and the patency rate for in situ saphenous vein bypass was 96 percent at 24 months, with a limb salvage rate of 80 percent at 24 months. Early results are promising for ankle bypass using the techniques of popliteal-to-distal and in situ bypass.

Internal iliac artery revascularization in the treatment of vasculogenic impotence

Five impotent men underwent internal iliac artery revascularization in conjunction with end-to-side aortobifemoral bypass after preoperative testing suggested a vasculogenic cause for impotence. All patients had abnormal preoperative penile/brachial arterial pressure indices (mean, 0.42 +/- 0.12). Following operation, all patients regained erectile capability and had normal postoperative penile/brachial indices (mean, 0.80 +/- 0.06). One patient developed retrograde ejaculation, emphasizing the need for meticulous nerve-sparing dissection with this operation. Internal iliac artery revascularization in conjunction with end-to-side aortobifemoral bypass is effective in relieving vasculogenic impotence in properly selected patients.

Sequential in-situ saphenous vein bypass. Early results and technique

This report summarizes early results with saphenous vein bypass (SVB) utilizing both sequential and in-situ techniques (SIS SVB) in eight limbs requiring limb salvage. SIS SVB was performed to a variety of vessel combinations using "Y" graft, continuous, or vein extension techniques achieving early patency in all limbs, despite pedal arch disease. Postoperatively, there was a significant increase in ankle/brachial Doppler indices (ABI) (P less than 0.001) at dorsal pedal (0.23-0.88) and at posterior tibial (0.32-0.91). Successful isolated popliteal grafting was confirmed by return of phasic Doppler wave forms. All but one limb healed with minimal tissue loss within 1 month of bypass. Preoperative high resolution angiography and clinical Doppler evaluation of saphenous vein anatomy are mandatory to determine candidacy for SIS SVB.

Crossover femorofemoropopliteal sequential bypass for combined ipsilateral iliac and femoropopliteal occlusive disease

We evaluated the effectiveness of crossover femorofemoropopliteal sequential bypass in 13 patients with combined ipsilateral iliac and femoropopliteal disease. Of them, eight underwent bypass grafting for limb salvage, and five, for disabling claudication. Four of the patients with claudication had relief of symptoms and significant increases in treadmill walking time. The cumulative limb salvage rate in the patients operated on for limb salvage was 88%. At 42 months, the cumulative patency rate for the femorofemoral portion of the graft was 91%, and for the distal segment, 63%. Mean ankle-brachial indices increased from 0.37 +/- 0.12 preoperatively to 0.76 +/- 0.16 postoperatively in the recipient limb. Early experience suggests that crossover sequential femorofemoropopliteal bypass grafts are effective in achieving limb salvage and relief of claudication, especially in patients with relative contraindications to major intra-abdominal surgery.

Clinical use of the seromuscular jejunal patch for protection of the infected aortic stump

Pathologic interactions between aortic prostheses and the gastrointestinal tract are very difficult problems in vascular surgery. After excision of the graft and proximal aortic closure, the major unsolved problem has been continued sepsis of the proximal aortic stump with subsequent fatal disruption. To provide healthy tissue for protection of this crucial area, we have devised a method in which a piece of jejunum on its vascular pedicle is opened along its antimesenteric border, the mucosa is removed, and the vascularized muscular wall is anchored to the aortic stump. This seromuscular jejunal patch was used clinically in three patients. Postmortem examinations in two of these patients 4 and 45 days postoperatively revealed no signs of infection, hematoma, or mucocele, and no histologic abnormalities; instead, the examinations did reveal firm tissue adherence between the aortic stumps and the seromuscular patches. The third patient is alive and well 1 year after this procedure. The three patients have demonstrated the feasibility of secure aortic stump protection by placement of well-prepared, vascularized seromuscular jejunal tissue over the potentially infected aortic stump. This technique may prevent postoperative stump dissolution and thus far appears to be a reasonable solution to this usually lethal problem.

Further experience with the saphenous vein used in situ for arterial bypass

Ongoing experience with use of the saphenous vein in situ as in infrainguinal arterial bypass is presented. One hundred eighty-three bypasses were performed for limb-threatening ischemia, 92 of which were to the popliteal artery, either isolated or in continuity with one or more tibial vessels, and 91 bypasses were carried to single tibial vessels below the termination of the popliteal artery. The results were analyzed by the life table method and show an overall patency rate of 89.8 percent at 3 to 4 years. Separate life table analysis of the tibial bypass group showed a patency rate of 83 percent at 3 to 4 years. Special emphasis is placed on the ability to use veins less than 4 mm in diameter, which comprise 40 percent of those used in these procedures. The superior results provided by the in situ method are explained in part by experimental observations which show that endothelial stability is completely preserved by this method but is severely disturbed during the process of vein removal and reversal.