End-to-end versus end-to-side venous microanastomoses in head and neck reconstruction

The Impact of Venous Anastomosis Technique on Outcomes of Free Tissue Transfer to the Head and Neck

Objectives: To evaluate the impact of different techniques of microvascular venous anastomosis on the outcome of free tissue transfer to the head and neck. Methods: Retrospective case series of patients undergoing microvascular free tissue transfer (MFTT) from January 2006 to September 2021. Chi-square tests and t-tests were utilized to identify differences in flap outcomes by technique, and log-binomial regression analyses were utilized to identify differences in flap outcomes by technique. Results: A total of 1055 consecutive MFTTs were analyzed. One hundred four cases required a return to the operating room for any reason, and 19 were attributed to venous compromise (18.0%). Ultimately, there were 22 FTT failures requiring complete revision (2.1%). In total, 1055 MFTTs involved 1352 venous anastomoses, ranging from 1 to 3 anastomoses in each case. End-to-end (ETE) was used 1040 times (76.9%) and end-to-side (ETS) 204 times (15.0%). The calculated risk ratio for venous complication for ETS compared with ETE was 1.17 (0.34-3.98). A microvascular coupler was used in 355 cases (33.6%). The calculated risk ratio for coupler compared with suture anastomoses was 0.92 (0.35-2.39). Conclusions: There were no significant difference in regard to outcomes of MFTT when comparing ETE with ETS, nor when comparing coupler with suture anastomoses.

Comparison of a coupling system and the suture method in end-to-side microvascular anastomosis in head and neck reconstruction

BACKGROUND

Use of coupling devices in microvascular anastomosis continues to increase, but it is not yet actively used in end-to-side (ETS) anastomosis because there is no standard method. Therefore, we propose an easy and time-saving ETS micro-anastomosis method using coupling devices in head and neck reconstruction and compare it with the conventional suture method.

MATERIALS AND METHODS

We retrospectively reviewed 30 consecutive cases (43 anastomoses) of ETS anastomosis in head and neck reconstruction from 2018 to 2022. Patient characteristics, operative details, and anastomosis time were evaluated. When using the coupling device, a cross incision was created in the recipient vessel to form vascular flaps. By pulling the flaps out of the ring, the intact vessel lining was fixed. Other procedures were the same as for a traditional anastomosis.

RESULTS

The mean anastomosis time was 12.81 min (range, 6.7-24.87) for the suture and 4.96 min (range, 2.02-9.4) for the coupling device, a statistically significant difference (p-value <.00005). There was no venous insufficiency or flap failure with either method.

CONCLUSIONS

ETS venous anastomosis using the coupling device is an easy-to-use, safe, and timesaving procedure for head and neck reconstruction.

Safety and reliability of the internal jugular vein for venous anastomoses in head and neck oncological reconstruction: A retrospective study

This study aimed to assess the efficacy of utilizing the internal jugular vein (IJV) as the primary recipient site for venous anastomoses in head and neck oncological reconstruction. Patients who underwent a free flap reconstruction of the head and neck were retrospectively included. Venous anastomoses were preferentially performed less than 1 cm from the IJV, either end-to-side (EtS) on the IJV, or end-to-end (EtE) on the origin of the thyrolingofacial venous (TLF) trunk. When the pedicle length was insufficient to reach the IJV, anastomoses were performed EtE to a size-matched cervical vein. Of the 246 venous anastomoses, 216 (87.8%) were performed less than 1 cm from the IJV, including 150 EtS on the IJV (61.0%), and 66 EtE on the TLF trunk (26.8%). Thirty veins (12.1%) were anastomosed EtE on other cervical veins more than 1 cm from the IJV. Two venous thromboses occurred (0.9%) and were successfully managed after revision surgery. There was no evidence of an increased thrombosis rate in high-risk or pre-irradiated patients. These findings suggest that the internal jugular vein is safe and reliable as a first-choice recipient vessel for free flap transfers in head and neck oncological reconstruction.

A simple free flap strategy using end-to-side anastomosis to the main vessels in injured extremity

Background

During free flap surgery, the surgeon sometimes encounters problems with anastomosis such as intractable arterial spasms or vessel size discrepancy in venous anastomoses. End-to-side (ETS) anastomosis has the advantages of limited chance of vessel spasm and easy handling by adjusting for vessel size discrepancy. We introduced the arterial and venous end-to-side anastomosis (AV-ETS) strategy, which is based on the ETS anastomosis to the main artery and accompanying veins, to avoid intraoperative anastomotic problems when creating a free flap. The aim of this study was to compare flap outcomes and intraoperative anastomotic problems before and after introduction of the AV-ETS strategy in extremity free flap surgery.

Materials and methods

We retrospectively examined 72 consecutive extremity free flaps. Before introducing the AV-ETS strategy, we used the conventional strategy in which the recipient artery was selected according to the number of the remaining main artery and the anastomosis technique was flexibly changed, although the end-to-end (ETE) technique was used in most cases.

Results

The conventional group had 18 flaps and the AV-ETS group had 54 flaps. The rate of flap survival did not differ between these groups, and there were no cases of flap failure after the introduction of the AV-ETS strategy. The AV-ETS group had significantly fewer flaps that required a change in preoperative planning for the recipient artery or anastomotic site of the artery.

Conclusions

The AV-ETS strategy may facilitate reliable preoperative planning and the performance of stable free flap surgery without requiring a flexible response during surgery.

Analysis of intraoral microvascular anastomosis in maxillofacial defects reconstruction

This review summarizes the research progress in the field of intraoral microvascular anastomosis techniques (IAT) and attempts to investigate the indications for procedures in which IAT can be applied, the surgical procedure and the difficulties involved, technical assessments, result evaluation and the perspective. Currently, microvascular anastomosis technique is widely used in maxillofacial defects reconstruction from various causes including cutaneous injury or congenital deformity which usually required extensive flap reconstruction and therefore a vascular free flap is routinely used. Conventional microvascular anastomosis reconstruction techniques cannot avoid new incisions, which will affect the postoperative aesthetic situation. Surgeons have therefore attempted to improve this technique to effectively eliminate scars caused by surgery: some patients can be chosen to undergo microvascular anastomosis of the free flap intraorally, thus reducing the extraoral incision caused by the anastomosis located in neck or maxillofacial improving the postoperative appearance of the patients. In addition to preserving the external appearance, intraoral anastomosis technique (IAT) can also solve some other problems of maxillofacial vascular anastomosis, such as insufficient vessel pedicle length and high risk of facial nerve injury.

End-to-side Anastomosis on Digital Arteries: Just a Technical Choice or a Real Benefit?

High-quality evidence is currently poor regarding the benefits of end-to-end (ETE) or end-to-side (ETS) anastomosis in arterial and venous anastomoses, despite being postulated as a potential influence on outcomes. A sufficient microvascular anastomosis is indispensable for the success of any free tissue transfer. ETS microvascular anastomoses have been becoming increasingly important as they allow reconstruction even in patients with impaired vascular status. To the authors’ knowledge, no studies have examined the choice of ETE or ETS anastomoses specifically for digital arteries.

Risk Factors for Free Flap Outcomes: A Retrospective Study of 318 Free Flaps for Head and Neck Defect Reconstruction

OBJECTIVES

This study was conducted to identify the risk factors for free flap outcomes in head and neck reconstruction.

METHODS

A retrospective review of 318 free flaps were used for head and neck reconstructions in 317 patients over seven years. The patient characteristics, surgical data, and flap outcomes were recorded. The impact of risk factors related on the outcomes of free flaps were analyzed using single and multivariate analysis.

RESULTS

For single factor analysis, 295 free flaps for the first reconstruction were included. Hypertension and the type of recipient vein are associated with venous thrombosis (P = .018, P = .047). Hypertension, type of free flap, recipient artery, and recipient vein were associated with the incidence of re-exploration (P = .009, P = .011, P = .017, P = .021). Hypertension had an obvious effect on the flap survival (P = .005). For multivariate analysis, hypertension (odds ratio = .166, 95% confidence interval: .043 - .636; P = .009) was a statistically significant risk factor for flap survival. For types of recipient artery and vein, selecting two venous anastomosis (one of IJVS and one of EJVS) had the minimum incidence of venous thrombosis (2.2%), and selecting facial artery, single vein (one of IJVS), and two veins (one of IJVS and one of EJVS) for anastomosis had lower incidence of re-exploration, which were 4.4%, 2.9%, and 6.0%, respectively (P < .05).

CONCLUSIONS

Risk factors as hypertension, type of free flap, recipient artery and vein should be paid more attention in the free flaps for head and neck reconstructions. We believe proper measures will lead to better results in head and neck reconstruction.

Outcomes of Venous End-to-Side Microvascular Anastomoses of the Head and Neck

Objectives/Hypothesis

The literature on outcomes of end‐to‐side (ETS) anastomoses for microvascular reconstruction of the head and neck is limited. This series reviews ETS in free tissue transfer (FTT) across multiple institutions to better understand their usage and associated outcomes.

Study Design

Retrospective review of 2482 consecutive patients across three tertiary institutions.

Methods

Adult patients (> 18) who received a FTT from 2006 to 2019 were included.

Results

Two hundred and twenty‐one FTT were identified as requiring at least one ETS anastomosis. These ETS cases had a failure rate of 11.2% in comparison to 3.8% in a cohort of end‐to‐end (ETE) cases (P < .001). ETS cases were significantly more likely to have a prior neck dissection (P < .001), suggesting the ETS method was utilized in select circumstances. A second ETS anastomosis improved survival of the FTT (P = .006), as did utilization of a coupler over suture (P = .002). Failure due to venous thrombosis was significantly more common with one ETS anastomosis instead of two ETS anastomoses (P = .042).

Conclusions

ETS is effective but is often used as a secondary technique when ETE is not feasible; as such, in this series, ETS was associated with higher failure. A second anastomosis and the use of the coupler for completing the anastomoses were associated with lower rates of failure.

Level of Evidence

3 Laryngoscope, 131:1286–1290, 2021

Analysis of Selection of Recipient Vein, Number of Outflows, Style and Technique in Head and Neck Venous Anastomosis and a Proposed Algorithm

Surgeons have preferential ways of performing venous anastomosis in head and neck microsurgery. However, controversies exist regarding the superiority of each method. This study aims to determine the effects of these variables on the rates of thrombosis and flap failure, and propose an algorithm to be used as a facilitator in the decision-making process. A total of 208 microsurgical reconstructions on 199 patients from a single surgeon's data were evaluated. Selection of recipient vein (superficial vs. deep), style of anastomosis (end-to-end vs. end-to-side), number of outflows (one vs. two) and technique of anastomosis (hand-sewn vs. coupler) were compared. Selection was done according to the pre- and intraoperative plan, as well as, surgeon's clinical judgement. Outcomes were determined as rates of venous thrombosis and flap failure. Five patients (2.4%) had venous problems, leading to two partial and three total flap failures. Selection of the recipient vein, style and number of outflows did not affect the outcomes, whereas coupler use decreased the rates of venous thrombosis and flap failure (p=0.008). Although it is difficult to set dogmatic criteria to achieve consistent outcomes, coupler use in this study prevented flap failure. An algorithmic approach was proposed with the results of the data and literature to increase the success in microsurgical anastomosis. Surgeons should use algorithms and sound judgement with adherence to microsurgical principles to obtain the best results for each patient.

Vein conduit for end-to-side anastomosis of a calcified vessel in lower extremity free flap reconstruction

BACKGROUND

As the microsurgical and interventional revascularization techniques are evolving, traditionally amputated limbs are now challenged to salvage. However, a calcified recipient vessel is a common but challenging problem encountered in lower extremity reconstruction.

METHODS

An end-to-side anastomosis of a vein graft (1.5-3.5 cm in length) was performed to the recipient vessel when it was difficult to clamp the recipient vessel near the defect because of the inelastic and hard vessel wall. The vascular clamp was applied to the vein graft, and the flap's pedicle was anastomosed to the vein graft.

RESULTS

A total of 18 free flaps (10 ALT cases, 4 TDAP cases, 2 PAP cases, and 2 SCIP cases) were anastomosed with a bridge vein graft to the heavily calcified recipient vessels (7 ATA cases, 3 PTA cases, 7 DPA cases, and 1 MPA case). Overall flap survival rate was 83.3%. Limb salvage rate was 93.7%, and anastomosis patency rate was 94.4% CONCLUSION: Vein conduit in an end-to-side anastomosis of severely calcified recipient vessels shows a reasonable limb salvage rate. It acts as a buffer, which makes microscopic vessel manipulation easier. If vessel calcification is the only drawback for a free flap reconstruction, then a vein graft needs to be prepared instead of an amputation. This method may extend the surgical option to more high-risk patients in lower extremity microsurgical reconstruction and increase the limb salvage rate.

Epidemiological and Histopathological Aspects of Tongue Squamous Cell Carcinomas-Retrospective Study

Tongue squamous cell carcinoma is one of the most commonly diagnosed intraoral squamous cell carcinomas (25-40%), being considered an aggressive form of squamous cell carcinoma, as it is most commonly associated with lymph node metastases and the survival rate at five years is below 50%. In according with these data, we have proposed in this study to individualize an epidemiological and histopathological profile of the patients with such oral cancers, diagnosed and treated in the Oral and Maxillofacial Surgery Clinic and in the Otolaryngology Surgery Clinic of the Emergency Clinical County Hospital Craiova, between 2015-2017. The cases were histopathologically reassessed according to the latest WHO classification of head and neck tumors, the variables of interest being the age of the patients, the gender, the lesion topography, the histological subtype, the degree of tumor differentiation, the pTNM stage, the resection margin status and the Brandwein-Gensler prognostic score. Thus, we recorded an average age of 55.81±14.98 tongue cancer development, 65% of the casuistry being diagnosed during the 7th and 6th decades, with a slight prevalence in men, with development in two thirds of cases in the mobile portion of the tongue. Histopathologically, conventional forms of squamous cell carcinoma prevailed (53.7%), followed by varieties: acantholytic (26%), basaloid (13%), sarcomatoid (5.45%) and verrucous (1.85%). Moderate differentiated forms prevailed (44.44%), half of the cases falling within the moderate degree of Brandwein-Gensler's histological risk score and two thirds were diagnosed in pTNM stage II and III of the disease, and a quarter of the cases having the margins invaded.

Characteristics and Management of Free Flap Compromise Following Internal Jugular Venous Thrombosis

PURPOSE

Free flap compromise after internal jugular venous thrombosis (IJVT) occurs fairly infrequently in oral and maxillofacial rehabilitation and reconstruction but could seriously affect the patient's postoperative recovery. The aim of this study was to analyze and discuss the characteristics and management of such flap compromise.

PATIENTS AND METHODS

The authors performed a retrospective case series of 13 patients who underwent reconstruction of oral and maxillofacial defects with anterolateral thigh flaps and developed flap compromise from IJVT from July 2014 through December 2016 at the Second Xiangya Hospital of Central South University (Changsha, China). The clinical features of flap compromise are described, and the precautions and improvement measures are reported.

RESULTS

All 13 patients were men with an average age of 50.3 years. Flap compromise caused by IJVT occurred on postoperative days 3 to 7, of which 2 flaps were salvaged (15.4%) and 11 flaps failed completely after immediate urgent re-exploration. Four patients presented with orocutaneous fistula after salvage surgery that healed well after a period of wound dressing.

CONCLUSIONS

Because of the late occurrence and low salvage rate of flap compromise caused by IJVT, intensive flap monitoring after reconstruction surgery is necessary for patients with free flap transfer.