Salvage of a free radial forearm flap by creation of an arteriovenous fistula at the distal arterial pedicle

Abstract

Interdisciplinary approaches with infrainguinal bypass grafts and free flaps between the plastic and vascular surgery may well offer an opportunity for diabetic patients with peripheral vascular disease to salvage their critically affected limbs. A free flap transfer combined with an autologous vein graft can cover large tissue defects and simultaneously improve distal perfusion even in patients with arterial occlusive disease. We are presenting a case of bypass-free radial forearm flap used to cover a foot defect in an old diabetic patient with peripheral arterial disease. The flap perfusion deteriorated significantly during the early postoperative period. The patient was brought back to the operating room with acute thrombosis of the popliteal-radial venous graft and the arterial pedicle of the flap. The flap was salvaged by thrombectomy and creation of an additional arteriovenous fistula at the distal arterial pedicle. The procedure improved the flap perfusion and decreased the high internal resistance that was noticed in the flap when trying to flush the radial artery during the revision surgery and was evident by continuous wave -Doppler sonography. The successful salvage of the flap in the presented case and the convenient long-term follow up suggest that this technique may be safe and helpful as a last effort to salvage a bypass-free flap with a suspected high internal resistance.

Salvage of a free osteocutaneous fibula flap by creating a distal arteriovenous fistula in facial reconstruction

“…Sidorov et al reduced high flap resistance using a distal AV fistula in a free radial forearm flap, applied in the reconstruction of a lower extremity defect. 8 Eweida et al 4 performed an AV fistula between the radial artery and a deep leg vein for forearm free flap salvage. They used the procedure during reconstruction of a foot defect and termed it 'arteriovenous flowthrough'.…”

“…For this reason, free flap salvage procedures continue to be developed and discussed. 4,5 Flow dynamics are one of the important causes of postoperative vascular thrombus in free flap surgeries. If a high volume of blood enters a high-resistance flap, vascular flow dynamics become labile and may initiate a thrombus, possibly resulting in flap failure.…”

Axially vascularised mandibular constructs: Is it time for a clinical trial?

“…13 fistula is less than 1 cm and the fistula accepts less than 20 percent of the cardiac output (Blaisdell et al, 1966;Tukiainen et al, 2006;Eweida et al, 2013;Horch et al, 2014). Regarding bone density and mineralization distal to an AV fistula, contradictory results are shown in the literature, ranging from an increase in bone growth (Vanderhoef et al, 1963) to decreased mineralization and augmented osteopenia (Muxi et al, 2009).…”

Distal pedal bypasses combined with free microsurgical flaps in chronic limb ischaemia for problematic wounds

“…In cachectic patients in whom no sufficient muscle tissues could be harvested, we have demonstrated the value of the greater omentum as a source of well-vascularised autologous tissue that can be combined with revascularisation processes (5). Surgical principles of radical wound debridement -regardless of underlying vital structures are exposed -and if necessary a second-look operation with intermittent negative pressure wound treatment, simultaneous or staged distal bypass grafting together with soft tissue transfer with an appropriate microvascular flap may help salvage limbs even when heavily infected wounds are present (6,7).…”