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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 29  |  Issue : 2  |  Page : 79-82

Comparing venous thrombosis rates in hand-sewn anastomosis to anastomotic coupler devices


Department of Plastic, Reconstructive and Aesthetic Surgery, Marmara University School of Medicine, Istanbul, Turkey

Date of Submission04-Jan-2020
Date of Acceptance30-May-2020
Date of Web Publication26-Mar-2021

Correspondence Address:
Dr. Zeynep Akdeniz Dogan
Marmara University School of Medicine, Basibuyuk Yolu, 9/2, Maltepe, İstanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_31_20

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  Abstract 


Background: Anastomotic coupling device (ACD) has reached wide popularity, especially in venous anastomosis of free-tissue transfers. There are scant reviews in the literature about the reliability of these devices in venous anastomosis. We retrospectively analyzed our free flap cases to compare the thrombosis rates between ACDs and handsewn anastomosis and other possible risk factors that may contribute to venous thrombosis. Materials and Methods: Data of all microvascular free-tissue transfers performed between January 2015 and August 2019 were retrospectively reviewed. Patient characteristics were recorded. Reconstruction characteristics such as venous anastomosis type (hand-sewn vs. anastomotic coupler device), reconstruction site, and number of surgical interventions were also recorded. Results: A total of 385 consecutive-free microvascular reconstructions were identified. Total venous thrombosis rate was 4.7%. There was no statistically significant difference between hand-sewn anastomosis and anastomosis with coupler device (5.2% vs. 3.2%, P = 0.58). Only reconstruction site was found to be significantly associated with higher venous thrombosis (P = 0.03). Discussion: Our results involving different reconstruction sites and including multiple flap types demonstrated comparable revision rates between ACDs and hand-sewn anastomosis. This finding is consistent with the current literature.

Keywords: Anastomotic coupler device, microsurgery, venous thrombosis


How to cite this article:
Dogan ZA, Aydin C, Cavus-Ozkan M, Sacak B, Bayramicli M. Comparing venous thrombosis rates in hand-sewn anastomosis to anastomotic coupler devices. Turk J Plast Surg 2021;29:79-82

How to cite this URL:
Dogan ZA, Aydin C, Cavus-Ozkan M, Sacak B, Bayramicli M. Comparing venous thrombosis rates in hand-sewn anastomosis to anastomotic coupler devices. Turk J Plast Surg [serial online] 2021 [cited 2021 Apr 23];29:79-82. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/2/79/312179




  Introduction Top


Anastomotic coupling device (ACD) has reached wide popularity since its first introduction.[1] It's design has been improved over the years,[2] and multiple studies have reported the efficacy and safety of these devices in several different anatomical regions.[3],[4],[5],[6],[7],[8],[9],[10],[11] The device has been shown to reduce ischemia time while maintaining vessel patency.[4]

There are studies in the literature comparing hand-sewn anastomosis to anastomosis with ACDs involving different anatomical regions with similar thrombosis rates.[3],[9],[11],[12],[13] The efficacy and high patency of ACDs may be explained by increased intimal contact and rigidity of the anastomosis site. Kulkarni et al. have actually shown the device to be more effective in preventing venous thrombosis compared to hand-sewn anastomosis in their 857 consecutive free flaps for breast reconstruction.[14]

We have looked at our experience and analyzed our free flap cases to compare the thrombosis rates between ACDs and hand-sewn anastomosis. We hypothesized that venous thrombosis rates would be similar in compliance with the current literature. Given that these devices reduce ischemia and operative time, similar thrombosis rates would possibly justify the cost for the health-care system. Our secondary objective was to look into other possible risk factors that may contribute to venous thrombosis.


  Materials and Methods Top


All of microvascular free-tissue transfers performed between January 2015 and August 2019 were retrospectively reviewed. Patient and reconstruction characteristics were extracted from the database. Patient characteristics such as age, gender, comorbidities, history of preoperative chemotherapy, and preoperative radiotherapy were recorded. Reconstruction characteristics such as venous anastomosis type (handsewn vs. anastomotic coupler device), reconstruction site (breast, head and neck, lower extremity, and others), and surgical interventions (primary vs. recurrent) were recorded. The primary outcome measure was venous thrombosis. Venous thrombosis was defined as thrombosis that required a return to the operating room and revision of the microvascular anastomosis with or without successful flap salvage. Patients with flap loss or anastomosis revisions due to arterial thrombosis were excluded from the study. All venous anastomosis were performed by one of the four attending plastic surgeons (ZAD, MÇÖ, BS, MB) with the assistance of a resident.

Statistical analysis

In order to evaluate the effects of patient and surgical characteristics on venous thrombosis, the Chi-square or Fischer's exact test was performed. P < 0.05 was considered statistically significant.


  Results Top


A total of 385 consecutive-free microvascular reconstructions were identified. Since this was a retrospective review, there were missing data on some of the patients or surgical characteristics that we were not able to locate on the database. Some patients received more than one free flap transfer (bilateral breast reconstructions, second flap following failures, or more than one flap for head and neck reconstruction). Each flap reconstruction was recorded as a separate data since each also required a separate microvascular anastomosis.

Mean age was 44.1 ± 17.2 years. Total venous thrombosis rate was 4.7%. Nearly 54.9% of reconstructions were performed on female patients and 45.1% were performed on male patients. 79.6% of patients did not have any comorbidities, whereas 20.4% had at least one comorbidity. 28.5% of all reconstructions were breast reconstructions, 40.7% were head and neck reconstructions, and 30.8% were lower extremity or other rarer reconstructions such as lymphedema surgery. A wide variety of flaps were used including muscle, fasciocutaneous, or bone flaps. [Table 1] summarizes the type and number of flaps performed.
Table 1: Type of Flaps Used for Reconstruction

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[Table 2] summarizes the patient and surgical characteristics that are associated with venous thrombosis. Only reconstruction site was found to be significantly associated with higher venous thrombosis rate (P = 0.03). There was no statistically significant difference between hand-sewn anastomosis and anastomosis with coupler device (5.2% vs. 3.2%, P = 0.58). History of preoperative chemotherapy or radiotherapy, gender, presence of comorbidities, and number of surgical interventions were not associated with a higher risk of venous thrombosis.
Table 2: Venous thrombosis rates

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Patient characteristics for hand-sewn anastomosis and ACD group are summarized in [Table 3]. The two cohorts were similar in terms of age, gender, preoperative radiotherapy, preoperative chemotherapy, and comorbidities.
Table 3: Comparison of two anastomosis groups

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  Discussion Top


Microvascular free-tissue transfer has been shown to be reliable with 1%–5% failure rates in large series.[15],[16],[17],[18] Venous thrombosis is still the major cause of free-flap failure. Therefore, technical methods developed to improve the outcomes while reducing operative time are of interest. ACDs have been proven to be effective and safe with comparable outcomes to hand-sewn anastomosis.[4],[10],[19] There are also reports in the literature demonstrating significant reduction in anastomotic time with the use of these devices.[3],[11] This, in return, reduces ischemia time and operative time. Prolonged ischemia time has been shown to be correlated with higher complication rates.[20],[21] There are even reports in the literature demonstrating improved outcomes with the use of ACDs in the breast region.[22]

Our results involving different reconstruction sites and different reconstruction modalities including multiple flap types, demonstrated comparable revision rates between ACDs and hand-sewn anastomosis. This finding is consistent with the current literature.

We have also evaluated other possible factors that may have an effect on venous revision rates. In their large series of 5643 free flaps, Hanson et al. have shown preoperative radiotherapy to be an independent predictor of venous thrombosis.[23] Although preoperative radiotherapy was not associated with a high-venous thrombosis rate in our series, two of the three patients who had venous thrombosis with ACD had a history of preoperative radiotherapy. Our results probably did not reach statistical significance due to relatively low number of patients.

Hanson et al. have shown higher thrombosis rate with 1.5 mm ACDs compared to larger sizes. This finding was only significant in the breast reconstruction cohort.[23] In the present study, the only variable that was associated with significantly higher venous thrombosis rates were the reconstruction site. In our series, breast reconstruction cases had significantly higher thrombotic events. This may be explained by the several factors. Breast reconstruction was performed most frequently with deep inferior epigastric artery flaps. These flaps depend highly on the communication between superficial and deep venous systems for venous outflow.[24],[25] They require a more thrill evaluation with computed tomography angiogram preoperatively to make sure that the surgeon picks the right perforators or possibly add a second vein anastomosis using the superficial system. Therefore, although we do not have a record of this, the venous problems encountered in these cases may not be entirely technical failures at the anastomosis site but rather intrinsic outflow issues. Furthermore, five out of ten venous thrombosis cases in the breast reconstruction group had a prior history of radiotherapy and as mentioned above, radiotherapy has been shown to be an independent predictor of venous thrombosis. These all may have contributed to higher rate of thrombosis in the breast area. In the head-and-neck region compared to other sites, there are also more number of recipient vessel options, making it more likely to choose veins with larger diameter. However, in the breast region, surgeons are limited by the available internal mammary vein or alternatively the thoracodorsal system.

The use of ACDs has a rather short-learning curve, yet still requires caution during the application. There is a risk of twisting the vein and injury to the intimal layer while everting the vessel. However, the coupler may provide a better intimal contact due to eversion and a stenting effect preventing turbulent flow.[14] However, in order to justify the use of ACDs in a socialized health care system, further cost analysis studies, including data on operative time, should be carried out. Our thrombotic events in the ACD group were distributed in time, making it unlikely to be related to experience. However, we did not investigate the experience of the surgeon in any of the cases, but it should be noted that anastomosis were performed by one of the four attending with the assistance of a resident. Unfortunately, we do not have the data on who actually performed each anastomosis since co-surgeoning (double scrubbing) is pretty common in our practice. Our study is also limited by the nonrandomized and retrospective design. The choice of using ACDs was dependent on both surgeon's preference and the availability of the device at the time of surgery rather than a prospective randomized design. It may be the surgeon's preference to hand-sew in order to overcome a significant size mismatch or the device may not be available which was not evaluated in this study. Another limitation of the study was that the only criteria for defining venous thrombosis was thrombosis that caused a clinical change on the flap and required a return to the OR. Therefore, there was no way to account for a possible vein thrombosis that went unnoticed because of the presence of a second venous anastomosis. Further studies designed in randomized prospective fashion are needed to truly show whether significant differences exist.


  Conclusion Top


Our results are consistent with the literature and demonstrate similar venous thrombotic event rates with the use of ACDs compared to hand sewing. Breast region seems to be associated with higher venous revision rates compared to other sites. We have attributed this to possible radiation effect and scarce number of recipient options in the region.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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14.
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23.
Hanson SE, Mitchell MB, Palivela N, Peng SA, Feng L, Largo RD, et al. Smaller diameter anastomotic coupling devices have higher rates of venous thrombosis in microvascular free tissue transfer. Plast Reconstr Surg 2017;140:1293-300.  Back to cited text no. 23
    
24.
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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