|Year : 2021 | Volume
| Issue : 2 | Page : 79-82
Comparing venous thrombosis rates in hand-sewn anastomosis to anastomotic coupler devices
Zeynep Akdeniz Dogan, Cem Aydin, Melekber Cavus-Ozkan, Bulent Sacak, Mehmet Bayramicli
Department of Plastic, Reconstructive and Aesthetic Surgery, Marmara University School of Medicine, Istanbul, Turkey
|Date of Submission||04-Jan-2020|
|Date of Acceptance||30-May-2020|
|Date of Web Publication||26-Mar-2021|
Dr. Zeynep Akdeniz Dogan
Marmara University School of Medicine, Basibuyuk Yolu, 9/2, Maltepe, İstanbul
Source of Support: None, Conflict of Interest: None
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 2023 Jan 31];29:79-82. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/2/79/312179
| Introduction|| |
Anastomotic coupling device (ACD) has reached wide popularity since its first introduction. It's design has been improved over the years, and multiple studies have reported the efficacy and safety of these devices in several different anatomical regions.,,,,,,,, The device has been shown to reduce ischemia time while maintaining vessel patency.
There are studies in the literature comparing hand-sewn anastomosis to anastomosis with ACDs involving different anatomical regions with similar thrombosis rates.,,,, 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.
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|| |
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.
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|| |
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 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.
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.
| Discussion|| |
Microvascular free-tissue transfer has been shown to be reliable with 1%–5% failure rates in large series.,,, 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.,, There are also reports in the literature demonstrating significant reduction in anastomotic time with the use of these devices., This, in return, reduces ischemia time and operative time. Prolonged ischemia time has been shown to be correlated with higher complication rates., There are even reports in the literature demonstrating improved outcomes with the use of ACDs in the breast region.
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. 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. 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., 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. 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|| |
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nakayama K, Tamiya T, Yamamoto K, Akimoto S. A simple new apparatus for small vessel anastomosisi (free autograft of the sigmoid included). Surgery 1962;52:918-31.
Ostrup LT, Berggren A. The UNILINK instrument system for fast and safe microvascular anastomosis. Ann Plast Surg 1986;17:521-5.
Rozen WM, Whitaker IS, Acosta R. Venous coupler for free-flap anastomosis: Outcomes of 1,000 cases. Anticancer Res 2010;30:1293-4.
Jandali S, Wu LC, Vega SJ, Kovach SJ, Serletti JM. 1000 consecutive venous anastomoses using the microvascular anastomotic coupler in breast reconstruction. Plast Reconstr Surg 2010;125:792-8.
Nylander G, Ragnarsson R, Berggren A, Ostrup LT. The UNILINK system for mechanical microvascular anastomosis in hand surgery. J Hand Surg Am 1989;14:44-8.
Ahn CY, Shaw WW, Berns S, Markowitz BL. Clinical experience with the 3M microvascular coupling anastomotic device in 100 free-tissue transfers. Plast Reconstr Surg 1994;93:1481-4.
Sasson HN, Stofman GM, Berman P. Clinical use of the 3M 2.5 mm mechanical microcoupling device in free tissue transfer. Microsurgery 1994;15:421-3.
Denk MJ, Longaker MT, Basner AL, Glat PM, Karp NS, Kasabian AK. Microsurgical reconstruction of the lower extremity using the 3M microvascular coupling device in venous anastomoses. Ann Plast Surg 1995;35:601-6.
DeLacure MD, Kuriakose MA, Spies AL. Clinical experience in end-to-side venous anastomoses with a microvascular anastomotic coupling device in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 1999;125:869-72.
Nishimoto S, Hikasa H, Ichino N, Kurita T, Yoshino K. Venous anastomoses with a microvascular anastomotic device in head and neck reconstruction. J Reconstr Microsurg 2000;16:553-6.
Yap LH, Constantinides J, Butler CE. Venous thrombosis in coupled versus sutured microvascular anastomoses. Ann Plast Surg 2006;57:666-9.
Barker EV, Enepekides DJ. The utility of microvascular anastomotic devices in head and neck reconstruction. Curr Opin Otolaryngol Head Neck Surg 2008;16:331-4.
Zhang T, Lubek J, Salama A, Caccamese J, Coletti D, Dyalram D, et al
. Venous anastomoses using microvascular coupler in free flap head and neck reconstruction. J Oral Maxillofac Surg 2012;70:992-6.
Kulkarni AR, Mehrara BJ, Pusic AL, Cordeiro PG, Matros E, McCarthy CM, et al
. Venous thrombosis in handsewn versus coupled venous anastomoses in 857 consecutive breast free flaps. J Reconstr Microsurg 2016;32:178-82.
Khouri RK, Cooley BC, Kunselman AR, Landis JR, Yeramian P, Ingram D, et al
. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998;102:711-21.
Yii NW, Evans GR, Miller MJ, Reece GP, Langstein H, Chang D, et al
. Thrombolytic therapy: What is its role in free flap salvage? Ann Plast Surg 2001;46:601-4.
Nakatsuka T, Harii K, Asato H, Takushima A, Ebihara S, Kimata Y, et al
. Analytic review of 2372 free flap transfers for head and neck reconstruction following cancer resection. J Reconstr Microsurg 2003;19:363-8.
Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: Indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg 2007;119:2092-100.
Ducic I, Brown BJ, Rao SS. Lower extremity free flap reconstruction outcomes using venous coupler. Microsurgery 2011;31:360-4.
Chang SY, Huang JJ, Tsao CK, Nguyen A, Mittakanti K, Lin CY, et al
. Does ischemia time affect the outcome of free fibula flaps for head and neck reconstruction? A review of 116 cases. Plast Reconstr Surg 2010;126:1988-95.
Ehrl D, Heidekrueger PI, Ninkovic M, Broer PN. Impact of duration of perioperative ischemia on outcomes of microsurgical reconstructions. J Reconstr Microsurg 2018;34:321-6.
O'Connor EF, Rozen WM, Chowdhry M, Patel NG, Chow WT, Griffiths M, et al
. The microvascular anastomotic coupler for venous anastomoses in free flap breast reconstruction improves outcomes. Gland Surg 2016;5:88-92.
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.
Rozen WM, Pan WR, Le Roux CM, Taylor GI, Ashton MW. The venous anatomy of the anterior abdominal wall: An anatomical and clinical study. Plast Reconstr Surg 2009;124:848-53.
Schaverien M, Saint-Cyr M, Arbique G, Brown SA. Arterial and venous anatomies of the deep inferior epigastric perforator and superficial inferior epigastric artery flaps. Plast Reconstr Surg 2008;121:1909-19.
[Table 1], [Table 2], [Table 3]