The Shunt-Restricted Arterialized Venous Flap for Hand/Digit Reconstruction: Enhanced Perfusion, Decreased Congestion, and Improved Reliability

Abstract

Restriction of arteriovenous shunting enhances peripheral perfusion and decreases congestion of venous flaps, thereby improving reliability and utility for hand/digit reconstruction.

The arterialized saphenous venous flow‐through flap with dual venous drainage

“…These purely venous type I and II flaps are expected to experience little pressure change in the afferent and efferent end of the flap and therefore perfusion of tissue would therefore be limited. 25 The largest type I flap to have survived was 10 3 12 surviving, but this is associated with a failure rate reported in the literature to be 30-80%. 20,24 Thatte and Thatte suggested a type II flap large as 18 3 6 cm 2 could be rotated in their 1989 article.…”

“…Much of this flow through may occur within the same vein or branches of the same vein. 25 This may be aided by denervation of the vein during dissection, resulting in dilation of veins and venules and relaxation of precapillary sphincters to allow reverse flow through the venules. 41 In addition, Nichter et al also postulated that oxygen may be utilized by precapillary and postcapillary vessels and not necessarily via capillaries only.…”

“…4,6,11,19,37 However, arterialized venous flaps tended to become congested and oedematous for up to 6 weeks postoperation in as many as 40% of cases. 25 Flap survival is likely dependent on changes and adaptation within the microcirculation. Although early neovascularization and plasmatic imbibition may also play an important role in the initial survival of smaller venous flaps, 38 especially those that are pure venous flaps, 6 larger flaps require adequate capillary microcirculation.…”

“…2,45,46 Of note, however, is that valves can become incompetent with sustained arterial pressure and with time, veins can also become incompetent when denervated. 25,47 The second element is that the flaps must contain a rich venous network for both the afferent and efferent veins. Additional draining veins are envisaged to reducing pressure within the venous pedicle and therefore reducing congestion and necrosis of the flap.…”

“…6 This higher rate of flap loss and failure, especially in larger flaps, has resulted in the venous flaps remaining an underutilized reconstructive option. 25 We report a modification in the design of saphenous venous flaps, whereby an arterialized saphenous venous flap is provided with a separate source of venous drainage and demonstrate survival of substantially larger venous flaps than previously reported.…”