The choice of microvascular anastomotic technique, end-to-end versus end-to-side, is still an item of debate. A review of the literature reveals no difference in patency rates in animal models where there is no size discrepancy. The available clinical evidence stems from Godina's early experience, proclaiming a higher failure rate with end-to-end anastomoses. Factors such as size mismatch and use of injured vessels, rather than anastomotic technique, may have been responsible. This clinical study examines the fate of over 2000 microvascular anastomoses performed in more than 900 tissue transplants. Complications attributable to the anastomosis were considered failures of the anastomosis, were tabulated, and were compared between the two techniques. The end-to-end and end-to-side microvascular techniques were found to be equally effective when properly applied. The choice of technique therefore should be secondary to factors influencing the choice of recipient vessel, such as the condition of the vessel, its accessibility, and the preservation or augmentation of maximal distal flow to an extremity.

During the past 20 years, 972 microvascular transplantations have been performed for 783 patients, with an overall failure rate of 6.2 percent. Fifty-four of the 60 failed transplantations were available for long-term follow-up and were retrospectively reviewed with respect to the original indications for transplantation, the number, and the type of salvage procedures performed following transplant failure. This study illustrates that the choice of salvage procedures performed following transplant failure depends on the original indications, the location, and the severity of the resultant wound. Failure following transplantation for coverage of contour defects or unstable wounds can often be managed by non-microsurgical methods. In contrast, when the indications for transplantation included the transfer of specialized tissues for thumb or digit reconstruction, the restoration of motor or sensory function, or the coverage of a limb-threatening wound, requirements for reconstruction could be satisfied only by a second successful tissue transplant. Eighteen of the 54 cases underwent an additional transplantation, with an 89 percent success rate.