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J Reconstr Microsurg 2020; 36(06): 432-437
DOI: 10.1055/s-0040-1702156
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Comparison of Outcomes of End-to-End versus End-to-Side Anastomoses in Lower Extremity Free Flap Reconstructions

Peter Niclas Broer‡   *
1   Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany
,
Nicholas Moellhoff   *
2   Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
,
Julius M. Mayer
2   Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
,
Paul I. Heidekrueger
3   Department of Plastic, Hand- and Reconstructive Surgery, University Medical Center, Regensburg, Germany
,
Milomir Ninkovic
1   Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany
,
Denis Ehrl
2   Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
› Author Affiliations
Further Information

Publication History

17 August 2019

05 January 2020

Publication Date:
29 March 2020 (online)

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Abstract

Background Whether to perform an end-to-end (ETE) versus end-to-side (ETS) arterial anastomosis is an integral part of preoperative planning and intraoperative decision making in free flap-based reconstructions. This study evaluated the impact of microsurgical anastomotic technique on outcomes of lower extremity reconstructions, with a focus on patients with peripheral arterial disease (PAD).

Methods Over a 6-year period, 425 patients underwent 437 microvascular lower extremity free flap reconstructions with fasciocutaneous anterolateral thigh- or gracilis muscle flaps at a single surgical center. The cases were divided into an ETE (n = 297 patients) versus ETS (n = 128 patients) group according to the anastomotic technique. A retrospective analysis of patients' demographics, perioperative details, surgical complications, free flap types, recipient sites, flap survival, and the potential impact of PAD on outcomes was performed. Patient groups were comparable regarding comorbidities, American Society of Anesthesiologists scores, types of performed free flaps and recipient sites.

Results We found no significant differences between the ETE versus ETS groups regarding the rate of major or minor complications (p > 0.05). Specifically, in patients suffering from PAD (n = 64) the type of arterial anastomosis had no effect on the outcome.

Conclusion Overall, no significant differences in outcomes were observed when comparing the types of performed arterial anastomosis. This observation also held true for the subgroup of patients with PAD. Given that an ETS anastomosis did not increase the risk to encounter complications while preserving distal perfusion, we believe that this technique is the method of choice, especially in patients with impaired vascular status.

Keywords

end-to-end anastomoses - end-to-side anastomoses - peripheral arterial disease

* These authors contributed equally to this work.


 

  • References

  • 1 Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg 1998; 102 (03) 599-616 , discussion 617–618
    CrossrefPubMedSearch in Google Scholar
  • 2 Attinger CE, Evans KK, Bulan E, Blume P, Cooper P. Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plast Reconstr Surg 2006; 117 (7, suppl): 261S-293S
    CrossrefPubMedSearch in Google Scholar
  • 3 Heidekrueger PI, Ninkovic M, Heine-Geldern A, Herter F, Broer PN. End-to-end versus end-to-side anastomoses in free flap reconstruction: single centre experiences. J Plast Surg Hand Surg 2017; 51 (05) 362-365
    CrossrefPubMedSearch in Google Scholar
  • 4 Godina M. Preferential use of end-to-side arterial anastomoses in free flap transfers. Plast Reconstr Surg 1979; 64 (05) 673-682
    CrossrefPubMedSearch in Google Scholar
  • 5 Samaha FJ, Oliva A, Buncke GM, Buncke HJ, Siko PP. A clinical study of end-to-end versus end-to-side techniques for microvascular anastomosis. Plast Reconstr Surg 1997; 99 (04) 1109-1111
    CrossrefPubMedSearch in Google Scholar
  • 6 Tsai YT, Lin TS. The suitability of end-to-side microvascular anastomosis in free flap transfer for limb reconstruction. Ann Plast Surg 2012; 68 (02) 171-174
    CrossrefPubMedSearch in Google Scholar
  • 7 Ahmadi I, Herle P, Miller G, Hunter-Smith DJ, Leong J, Rozen WM. End-to-end versus end-to-side microvascular anastomosis: a meta-analysis of free flap outcomes. J Reconstr Microsurg 2017; 33 (06) 402-411
    Thieme ConnectPubMedSearch in Google Scholar
  • 8 Zhang L, Moskovitz M, Piscatelli S, Longaker MT, Siebert JW. Hemodynamic study of different angled end-to-side anastomoses. Microsurgery 1995; 16 (02) 114-117
    CrossrefPubMedSearch in Google Scholar
  • 9 Daigeler A, Kneser U, Fansa H, Riester T, Uder M, Horch RE. ; Deutschsprachige Gemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße. Reconstruction of the vascular compromised lower extremity—report of the consensus workshop at the 35. Meeting of the DAM (Deutschsprachige Gemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße) 2013 in Deidesheim [in German]. Handchir Mikrochir Plast Chir 2014; 46 (04) 248-255
    Thieme ConnectPubMedSearch in Google Scholar
  • 10 Pu LL. A comprehensive approach to lower extremity free-tissue transfer. Plast Reconstr Surg Glob Open 2017; 5 (02) e1228
    CrossrefPubMedSearch in Google Scholar
  • 11 Fischer JP, Wink JD, Nelson JA. , et al. A retrospective review of outcomes and flap selection in free tissue transfers for complex lower extremity reconstruction. J Reconstr Microsurg 2013; 29 (06) 407-416
    Thieme ConnectPubMedSearch in Google Scholar
  • 12 Koul AR, Patil RK, Nahar S. Unfavourable results in free tissue transfer. Indian J Plast Surg 2013; 46 (02) 247-255
    Thieme ConnectPubMedSearch in Google Scholar
  • 13 Cho EH, Garcia RM, Blau J. , et al. Microvascular anastomoses using end-to-end versus end-to-side technique in lower extremity free tissue transfer. J Reconstr Microsurg 2016; 32 (02) 114-120
    Thieme ConnectPubMedSearch in Google Scholar
  • 14 Ahmadi I, Herle P, Miller G, Hunter-Smith DJ, Leong J, Rozen WM. End-to-end versus end-to-side microvascular anastomosis: a meta-analysis of free flap outcomes. J Reconstr Microsurg 2017; 33 (06) 402-411
    Thieme ConnectPubMedSearch in Google Scholar
  • 15 Criqui MH, Aboyans V. Epidemiology of peripheral artery disease. Circ Res 2015; 116 (09) 1509-1526
    CrossrefPubMedSearch in Google Scholar
  • 16 Oh TS, Lee HS, Hong JP. Diabetic foot reconstruction using free flaps increases 5-year-survival rate. J Plast Reconstr Aesthet Surg 2013; 66 (02) 243-250
    CrossrefPubMedSearch in Google Scholar
  • 17 Hong JP, Oh TS. An algorithm for limb salvage for diabetic foot ulcers. Clin Plast Surg 2012; 39 (03) 341-352
    CrossrefPubMedSearch in Google Scholar
  • 18 Salvo NL, Walsh MD, Brewster LP. Promoting limb salvage through multi-disciplinary care of the diabetic patient. Curr Treat Options Cardiovasc Med 2017; 19 (07) 55
    CrossrefPubMedSearch in Google Scholar
  • 19 Kneser U, Arkudas A, Beier JP. , et al. Extended skin and soft tissue defects after vascular wounds: plastic surgical concepts [in German]. Zentralbl Chir 2013; 138 (05) 536-542
    Thieme ConnectPubMedSearch in Google Scholar
  • 20 Czerny M, Trubel W, Zimpfer D. , et al. Limb-salvage by femoro-distal bypass and free muscle flap transfer. Eur J Vasc Endovasc Surg 2004; 27 (06) 635-639
    CrossrefPubMedSearch in Google Scholar
  • 21 Haddock NT, Weichman KE, Reformat DD, Kligman BE, Levine JP, Saadeh PB. Lower extremity arterial injury patterns and reconstructive outcomes in patients with severe lower extremity trauma: a 26-year review. J Am Coll Surg 2010; 210 (01) 66-72
    CrossrefPubMedSearch in Google Scholar
  • 22 Chou C, Kuo PJ, Chen YC. , et al. Combination of vascular intervention surgery and free tissue transfer for critical diabetic limb salvage. Ann Plast Surg 2016; 77 (suppl 1): S16-S21
    CrossrefPubMedSearch in Google Scholar
  • 23 Seth AK, Iorio ML. Super-thin and suprafascial anterolateral thigh perforator flaps for extremity reconstruction. J Reconstr Microsurg 2017; 33 (07) 466-473
    Thieme ConnectPubMedSearch in Google Scholar
  • 24 Cho EH, Shammas RL, Carney MJ. , et al. Muscle versus fasciocutaneous free flaps in lower extremity traumatic reconstruction: a multicenter outcomes analysis. Plast Reconstr Surg 2018; 141 (01) 191-199
    CrossrefPubMedSearch in Google Scholar
  • 25 Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109 (07) 2219-2226 , discussion 2227–2230
    CrossrefPubMedSearch in Google Scholar
  • 26 Franco MJ, Nicoson MC, Parikh RP, Tung TH. Lower extremity reconstruction with free gracilis flaps. J Reconstr Microsurg 2017; 33 (03) 218-224
    Thieme ConnectPubMedSearch in Google Scholar
  • 27 Zachara M, Drozdowski P, Wysocki M, Siewiera I, Wójcicki P. Anatomical variability of the anterolateral thigh flap perforators between sexes: a cadaveric study. Eur J Plast Surg 2013; 36 (03) 179-184
    CrossrefPubMedSearch in Google Scholar
  • 28 Magden O, Tayfur V, Edizer M, Atabey A. Anatomy of gracilis muscle flap. J Craniofac Surg 2010; 21 (06) 1948-1950
    CrossrefPubMedSearch in Google Scholar
  • 29 Park S, Han SH, Lee TJ. Algorithm for recipient vessel selection in free tissue transfer to the lower extremity. Plast Reconstr Surg 1999; 103 (07) 1937-1948
    CrossrefPubMedSearch in Google Scholar