Comparison of hand-sewn versus modified coupled arterial anastomoses in head and neck reconstruction: a single operator's experience

[Mechanical vascular anastomoses]

BACKGROUND

Mechanical anastomoses of blood vessels represent a major advance in modern surgery. Highly specialized instruments ensure the precise connection of blood vessels, enabling the immediate restoration of blood flow. Ring coupler systems for venous anastomoses, in particular, have proven themselves in clinical practice due to their convenience and reliability and are now an indispensable part of surgical routines.

OBJECTIVES

Precise and functionally proper anastomosis of blood vessels; shortening of the anastomosis time; minimization of perfusion disorders in the affected tissue; reduction of intraoperative and postoperative complications.

INDICATIONS

Replantation of extremities after amputations and injuries; defect reconstruction using free flaps; microsurgical vascular bypass procedures.

CONTRAINDICATIONS

Severe vascular pathologies such as vascular aneurysms, arteriosclerosis or severe inflammation in the area of the anastomosis; large differences between the vessel lumina; too small or too large vessels.

SURGICAL TECHNIQUE

Clamping of both vessel ends; selection of the appropriate ring coupler size based on the vessel diameter; mobilization of at least 1 cm at each vessel end; functional testing of the coupler device; threading the vessels, securely joining the rings and removing the holding device; removing clamps, inspection of the anastomosis.

POSTOPERATIVE MANAGEMENT

Regular blood circulation checks; avoiding pressure on the anastomosis; adequate anticoagulation.

RESULTS

Precise anastomoses; reduction in operating time.

Exploring the supremacy of microvascular coupling devices for arterial anastomosis in terms of added expeditiousness, safety concerns: A systematic review

Background

Arterial anastomoses are still most commonly performed using orthodox hand sewing technique. Various rationale such as non-pliable, atherosclerotic, thick-walled or irradiated vessels limit the competency of coupler devices for arterial micro-anastomosis. Microvascular coupling devices (MCD) are well known for venous anastomoses but arterial MCD have relatively been less navigated in reported literatures. This review outlines the current applications, troubleshooting, safety and efficiency of arterial MCD in free flaps.

Methods

Comprehensive search of electronic databases (PUBMED/MEDLINE) in accordance with PRISMA guideline was performed. Data were extracted and collected in four groups of standardised variables.

Results

Out of a total of 263 identified articles, 38 studies were analysed and 16 amidst these were included in final data synthesis. Included studies contained a combined total of 2416 patients who went through 521 arterial and 2460 venous anastomoses using 3 M/Synovis coupling devices. Among all coupled arterial anastomoses, 407 were conducted in head and neck free tissue transfer and 114 were performed in breast reconstruction. The aggregate coupled arterial micro-anastomosis success rate reported was 90.01 % (469/521). Only 9.98 % (52 out of 521) manifested pooled incidence of troubleshooting, thrombosis or flap failure.

Conclusion

Microsurgeons are resisting the frequent use of arterial coupling devices owing to inherent arterial characteristics, but with suitable vessel selection, arterial coupling may be a powerful tool and can be executed in safe, expeditious and reliable fashion. This study embellishes collaborative suggestions and troubleshooting issues related to arterial coupling, however further assessment would be required with controlled trials.

Comparison of the microvascular anastomotic Coupler™ system with hand-sewn suture for end to end veno-venous anastomosis for head and neck reconstruction with free flap transfer: Medico-economic retrospective case-control study

The aim of this study was to assess the medico-economic impact of the MACD Coupler™ system in comparison with HSA for end to end veno-venous anastomosis during free flap transfer. A retrospective case-control study was performed in an academic institution, from March 2019 through July 2021, to analyze medical and economic outcomes of patients managed for head and neck reconstruction with free flap transfer. 43 patients per group were analyzed. Rates of initial success, re-intervention, complications and flap transfer failure were not different between groups. Use of MACD increased the cost of medical devices between Coupler and Control groups with respectively K€ 0.7 [0.5; 0.8] and K€ 0.1 [0.5; 0.8] (p = 0.001) and decreased the cost for operating staff with respectively K€ 4.0 [3.4; 5.2] and K€ 5.1 [3.8; 5.4] (p = 0.03). The total management costs were not different between groups with respectively a total median cost of K€ 18.4 [14.3; 27.2] and K€ 17.3 [14.1; 23.7] (p = 0.03). In conclusion, the cost of the Coupler™ is significant but is partly offset by the decrease in operating staff costs. The choice of one or the other technique can be left to the discretion of the surgeon.

Evaluation of Anastomosis Efficiency in Arteriovenous Shunts Created by Using Hand-Sewn Microsurgery and Microvascular Anastomotic Coupler Device

OBJECTIVE

Microsurgery has made great contributions to the advancement of surgery. In parallel with the developments in microsurgery, various techniques have been developed to perfect the technique. Microvascular anastomotic coupler device (MACD) is one of these techniques. The aim of the study was to evaluate the effectiveness of anastomoses created by using hand-sewn microsurgery (HSM) and MACD.

METHODS

Twenty male Sprague-Dawley rats weighing 250 to 300 g were divided into 2 groups randomly. Arteriovenous shunt was performed between carotid artery and internal jugular vein with the principles of HSM in the first group (n=10) and by using the 1-mm anastomotic microvascular device in the second group (n=10). Groups were evaluated for anastomose time, success of anastomosis, thrombosis formation, color Doppler ultrasonography, and histopathological features.

RESULTS

Anastomotic time was faster with the coupler device compared with HSM technique. Flow rates were found significantly higher in the MACD group. Endothelialization and wall integrity rates were better in MACD group.

CONCLUSIONS

Microvascular anastomotic coupler device is faster than HSM. High quality and durability of vascularization, insignificant foreign body reactions are histopathological advantages of MACD.

[Reconstruction of Head and Neck Defects after Cancer Surgery]

Cancer surgery in the head and neck region often results in complex defects. The reconstructive ladder was developed to guide treatment decisions. In the head and neck region the most straightforward reconstructive technique is often not the most suitable, because it is comprised of many functional and aesthetic subregions that lie close together. If primary closure, secondary wound healing or negative wound pressure therapy are not an option, skin grafting is the next step. Larger or aesthetically and functionally challenging defects are often reconstructed with flap surgery. It is distinguished between local or regional flaps that are rotated or transposed into the defect and distant flaps. The blood supply of local/regional flaps is either random pattern or axial pattern, distant flaps are pedicled or free flaps. The vessels of free flaps are connected to the blood supply in the defect by microvascular anastomoses. The radial forearm flap, the pectoralis major flap and the anterolateral thigh flap are the most common distant flaps in the head and neck region. Preoperative planning is the most important step in reconstructive surgery. The method of reconstruction must be suited to the functional and aesthetic requirements of the defect but also to the morbidity and compliance of the patient and the surgical expertise of the clinic. Not only immediate postoperative complications such as insufficient anastomosis, infections or hematoma but also later, mostly functional complications such as dysphagia or dyspnea must be taken into consideration when planning the reconstruction of a defect in the head and neck region.

Israeli Innovations in the Field of Plastic Surgery

Numerous innovations within the field of plastic surgery have been developed in Israel over the last few decades. Many of these therapeutic devices and techniques have been established globally with demonstrable efficacy and respectable safety profiles. This article offers an overview of recent Israeli cutting-edge medical therapeutic solutions contributing to the global practice of plastic surgery.

Comparison between an Operating Surgical Microscope and High Magnification Surgical Loupes in Microvascular Reconstruction of Head and Neck Defects in a Tertiary Healthcare Centre

Introduction and Objective

Microvascular free tissue transfers have become an important method of reconstruction following head & neck oncological resection. The objective of this study was to evaluate the efficacy of surgical loupes against surgical operating microscope, which is the gold standard for microvascular anastomosis and also to explore the possibility of surgical loupes as an essential cost-effective armamentarium in head and neck reconstruction.

Materials and Methods

This prospective randomized study included 40 patients diagnosed with head and neck malignancies, requiring microvascular free flap reconstruction. A total of 20 patients who underwent free flap reconstruction following oncologic/maxillofacial defects using high magnification surgical loupes & the other 20 patients were subjected to reconstruction under an operating surgical microscope. The efficacy was assessed based on the following parameters. 1. Total operating time taken for completing anastomosis. 2. Overall fatigue. 3. Free flap failure rate.

Results

The microscope group took an overall mean time of 34.26 min considering its limited degree of freedom in adjusting intraoperatively whereas the loupes group had a shorter mean anastomosis time 33.29 min considering its ease of operator adjustability. Overall, fatigue was compared using Mann-Whitney Test and found to be statistically significant with P value of 0.17, the loupe group was found to be better with mean score of 6.90 in 21 patients than microscope with mean score of 6.21in 19 patients. Flap survival rate in the loupe group had two cases of venous obstruction at 24 h follow-up and microscope group had 1 case of venous.obstruction.

Conclusion

The success with loupe only free tissue transfer can be attributable considering expertise with the microscope and the loupes can be a cost-effective alternative to microscope.

Differences in free flaps’ reconstructions with and without coupling device for venous anastomosis

<br><b>Introduction:</b> Introduction of the coupler devices for anastomoses of neck vessels changes planning and performance of the surgical procedures. The Rigid ring of the coupling devices keeps a vein open and less prone to occlusion. Therefore, this should improve the flap survival rate and surgery duration.</br> <br><b>Aim:</b> The aim of the study was to point out the differences in surgery planning between couplers and sutures for venous microsurgical anastomoses.</br> <br><b>Methods:</b> The medical records of 209 patients who underwent 212 microvascular free flap reconstructions from January 2011 till December 2017 were retrospectively analyzed; 103 received radial forearm free flap (RFFF); 43 – anterolateral thigh flap (ALTF); 51 – fibula free flap (FFF); 15 – iliac crest free flap (ICFF). In 189 cases, reconstruction was performed simultaneously with tumor resection and in 23 cases, reconstruction was secondary, after previous oncological treatment. Among 443 anastomoses, suturing was used for 212 arteries and 127 venous anastomoses, while coupling was used for 104 venous anastomoses.</br> <br><b>Results:</b> The mean surgery duration for suturing was 452.82 min vs 358.88 min for coupling (P<0.05). Differences in flap survival and partial necrosis rates between coupling and suturing groups were not statistically significant (P>0.05). Donor vessel distribution in the neck was significantly different in both groups. Estimated costs of the surgical procedures performed with and without coupler devices were not equal.</br> <br><b>Conclusions:</b> The use of couplers for venous anastomosis in free flap head and neck reconstructions impacts the surgery process by shortening surgery duration which leads to cost reduction.</br>

Meta-analysis of arterial anastomosis techniques in head and neck free tissue transfer

The present meta-analysis aimed to investigate the differences in the incidence of thrombosis and vascular compromise in arterial anastomosis between microvascular anastomotic devices and hand-sewn techniques during free tissue transfer in the head and neck. We searched for articles in PubMed/Medline, CNKI, WANFANG DATA, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Web of Science, from January 1, 1962 till April 1, 2020 that reported data of microvascular anastomosis during free tissue transfer in the head and neck. The incidence of arterial thrombosis or vascular compromise, or both was the primary outcome. The secondary outcome was anastomotic time. We also assessed the sensitivity and the risk of bias. This meta-analysis included 583 arterial anastomoses from six studies. The group using microvascular anastomotic devices tended to have an increased incidence of arterial thrombosis and vascular compromise (risk ratio (RR), 3.42; P = 0.38; 95% confidence interval (CI), 0.91–12.77). The hand-sewn technique took significantly longer to perform the anastomosis compared with that of the microvascular anastomotic devices (weighted mean difference, 15.26 min; P<0.01; 95% CI, 14.65–15.87). Microvascular anastomotic devices might increase the risk of arterial thrombosis and vascular compromise compared with the hand-sewn technique; however, further randomized controlled trials are needed to provide a more accurate estimate. The application of microvascular anastomotic devices will help to reduce anastomotic surgery time and achieve acceptable vessel opening, benefiting from the developments of arterial couplers and microsurgical techniques.

Microvascular anastomotic arterial coupling: A systematic review

INTRODUCTION

There are several reasons microsurgeons may not use a coupler device in arterial anastomosis: may be thick-walled, non-pliable due to atherosclerotic calcification or present vessel geometrical discrepancies. This review summarises the current applications, efficacy and troubleshooting of microvascular coupler devices in arterial end-to-end anastomosis.

METHODS

A systematic review of the literature was performed in November 2020 across 4 electronic databases and in accordance with the PRISMA guidelines. All studies comprised the data synthesis that reported the use of a microvascular coupler device for arterial end-to-end anastomosis. Data were extracted and collected in three groups of standardised variables: study, anastomosis-related and technical characteristics.

RESULTS

Out of the 7,690 articles identified, 20 were included in the final data synthesis. Included studies involved a total of 1639 patients, who underwent 670 arterial and 1,124 venous anastomoses. Out of all arterial anastomoses, 351 were performed in free tissue transfers in head and neck, 117 in breast, 4 in upper extremity and 5 in lower extremity reconstruction, whereas the remaining were not specified. The total arterial coupler anastomosis success rate reported was 92.1% (617/670). Fifty-three (8%) arterial anastomoses were reported to result in either troubleshooting events or intra- or post-operative failures, most being reported in extremity reconstructions.

CONCLUSIONS

Arterial coupling is not widespread with predominant use in head and neck and chest reconstructions, and total reported efficacy of 92.1%. Microsurgeons are reluctant to routinely use current widespread coupler devices as a result of inherent arterial characteristics. This study delivered collective recommendations, 'do's and don'ts' of microvascular arterial coupling.

A retrospective analysis of the surgical outcomes of different free vascularized flaps used for the reconstruction of the maxillofacial region: Hand-sewn microvascular anastomosis vs anastomotic coupler device

The aim of the study was to assess the surgical outcomes following venous anastomosis with a coupling device and hand-sewn anastomosis in the reconstruction of the maxillofacial region. The study sample was recruited from patients who underwent reconstructive surgeries between January 2011 and November 2016. Tumor type, recipient veins, distribution of flap type, flap survival rates and anastomosis associated complications requiring a flap revision were documented. The follow-up period was four years. In total, 236 patients were included in this study, in which 201 reconstructions were performed via microsurgical venous coupling device (82.04%), whereas hand sewn anastomosis was used in 44 patients (17.96%). Postoperative complications regarding the anastomosis technique revealed that venous coupler devices showed significantly lower complications (4,97%) compared to hand sewn anastomosis (11,36%) (p < 0.05). Within the limitations of the current study, it can be concluded that the coupler system does appear to have advantages over conventional hand-sewn venous anastomosis and should be preferred when possible.

Microvascular anastomotic coupler devices versus hand-sewn technique for arterial anastomosis: a systematic review

The use of microvascular anastomotic coupling devices (MACD) is an established technique for venous anastomosis. However, literature on arterial MACD is conflicting. We report, to our knowledge, the first registered systematic review of its kind to evaluate the safety and efficiency of arterial MACD in free flaps. We performed a PRISMA-guided systematic review (PROSPERO-registered) and identified reports using a search algorithm in MEDLINE/EMBASE. The rate of arterial thrombosis was set as the primary outcome. Secondary outcomes included flap survival, failure rates, and comparison of MACD and the conventional hand-sewn technique. From the 17 studies identified, 2672 free flap reconstructions were performed and 640 arterial anastomoses with MACD attempted (622 completed, 97.2%). The pooled incidence of arterial thrombosis was 2.1% (13/622), and overall flap failure rate 4.34% (116/2672). The total number of arterial MACD procedures performed first time, with no perioperative complications, revisions, or thrombosis, was 88.9% (569/640). Grading of Recommendations, Assessment, Development and Evaluation (GRADE) quality analysis revealed low quality and significant heterogeneity. The use of arterial MACD is a safe and efficient alternative to hand-sewn anastomosis, with more recent literature showing excellent results. However, further evaluation is required with controlled trials.