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Introduction: Microsurgery cases utilizing interpositional vein grafts (IVG) are reported to have higher rates of flap failure than cases where primary anastomosis is possible. In cases where additional pedicle length is needed for anastomosis, IVGs are often the only option to bridge a gap. The purpose of this study was to critically examine outcomes following interpositional vein grafting to determine the true utility of this microsurgical technique.
Methods: We performed a retrospective review of all microsurgery cases performed at a single institution from 2005 to 2011. We determined cases which required interpositional vein grafting for reconstruction. Cases utilizing IVGs in the primary procedure, as well as cases which required an IVF during takeback or salvage attempts were included. Additional data was collected regarding flap type, indications for the IVG, microsurgery case type, need for heparin or thrombolytics, graft origin and outcome. We examined the cohort overall, and performed a subgroup analysis by timing of initial IVG (at the primary procedure or as a salvage attempt).
Results: Overall, 1772 patients underwent 2368 free flaps during the study period. We determined that 53 IVGs were utilized in 43 patients (2.4%) and 43 flaps (1.8%). Twenty (47%) were utilized in the primary free tissue transfer, while 23 (53%) were utilized during a flap salvage. The saphenous vein was the most common graft donor vessel (86%). Forty-four percent were used in breast reconstruction, 28% in lower extremity reconstruction, 21% in head and neck reconstruction and 7% for trunk/chest wall reconstruction. The grafts were most commonly utilized for venous anastomosis (n=16, 37%), although IVG were also utilized for arterial anastomosis (33%), AV loop formation (14%) and both AA and venous anastomosis (16%). Ninety one percent of flaps were systemically heparinized. Overall, 9 total flap losses (21%) occurred when IVGs were utilized.
Subgroup analysis revealed that IVG utilized in the primary procedure (n=20) had a 100% success rate. These were most commonly utilized in lower extremity cases (n=10, 50%). Three grafts (15%) did experience thrombosis intraoperatively and were revised, while 1 (5%) experienced a delayed arterial thrombosis. Alternatively, when utilized in a salvage attempt, which were most commonly breast reconstruction cases (n=13, 57%), the flap loss rate increased to 39% (9/23 flaps). Upon further examination of this cohort, we determined that when utilized for a salvage secondary to venous thrombosis, flap survival was 73%. However, when utilized for reconstruction following an arterial thrombosis, the success dropped to 50% (6/12 flaps).
Conclusions: This study demonstrates that IVGs can attain an excellent success rates are attainable when utilized in a primary free tissue transfer, although careful examination of the IVG is warranted. When performed during a salvage attempt, success appears to depend more on the evolving thrombotic process. Specifically, salvage of a venous thrombosis appears to be easier using an IVG than an arterial thrombosis. We suggest systemic anticoagulation in cases where IVGs are performed.