Versatility of a posterior‐wall‐first anastomotic technique using a short‐thread double‐needle microsuture for atherosclerotic arterial anastomosis

Abstract

To perform safe anastomosis for atherosclerotic arteries, we employed a posterior-wall-first anastomotic technique with a short-thread double-needle microsuture. Between October 2005 and September 2007, we performed 17 free flap transfers to the head and neck regions with this technique. Fifteen of 17 patients had one or more risk factors for atherosclerosis. In all patients except one, the superior thyroid artery was employed as a recipient artery and end-to-end anastomosis was performed close to its origin with the external carotid artery. Postoperatively, no anastomotic thrombosis occurred in any patients. The greatest advantage of the double-needle microsuture is that each stitch can be placed from the inner side of the arterial wall to the outer side. This "inner-to-outer" stitch secures full-thickness bite and minimizes intimal damage. Safe and reliable anastomosis could be carried out in an unfavorable setting because the double-needle suture offers a high degree of freedom in suture placement.

Feasibility of Microvascular Head and Neck Reconstruction in the Setting of Calcified Arteriosclerosis of the Vascular Pedicle

“…14 For those with a known history of atherosclerosis, considerations and appropriate adjustments are made to the treatment plan preoperatively and intraoperatively, as has been described by Chen et al 7 and Miyamoto et al 8 These considerations may include selection of a flap donor site less commonly affected by atherosclerotic disease, alterations in the selection of recipient vessels, and adjustment of the surgical technique to minimize potential disruption of atherosclerotic plaques during the preparation and execution of the microvascular anastomosis.…”

“…The presence of atherosclerosis has often been cited as a significant risk factor for flap failure and perioperative complications. [7][8][9][10] A number of mechanisms have been identified as contributing to the increased risk of flap failure in atherosclerotic patients. The tunica intima of atherosclerotic vessels is vulnerable to separation from the tunica media, exposing the thrombogenic subepithelium and elevating the risk of anastamotic failure secondary to vascular thrombosis.…”

“…This risk is thought to be elevated in patients with arteriosclerosis. 8,11 In addition, the severity of atherosclerosis affecting the donor vessels may entirely preclude the use of certain free flaps. This is a wellknown consideration during the preoperative evaluation of lower-extremity donor sites such as the fibula osteocutaneous free flap, and preoperative vascular imaging studies are often performed in these patients to rule out the possibility of occluded or stenotic vessels and to evaluate for atherosclerotic vascular malformation.…”

“…7 In particular, the presence of arteriosclerosis affecting the donor or recipient vessels has been identified as increasing the complication rate and the technical difficulty of free flap reconstruction. 8,9 There are several mechanisms on which this assertion is founded. In the setting of arteriosclerosis, there is a purported increased risk of separation of the tunica intima from the tunica media with the passing of transmural sutures during the microvascular anastomosis.…”

“…This may subsequently contribute to an elevated risk of thrombosis and anastamotic failure. 8 In addition, the arteries used for the microvascular anastomosis in atherosclerotic patients may lose their elasticity secondary to vascular calcifications, rendering the arrangement of ideal pedicle geometry particularly challenging.…”