Abstract
Free-flap surgery has become a routine procedure in breast reconstruction. The microvascular surgical anastomosis remains one of the technically sensitive aspects of free-tissue transfers. Between December 2006 and September 2007, 12 anastomoses were performed with a venous coupling device from Synovis. There were no free-flap failures. Venous congestion occurred in only one case and was managed successfully with leeches. No major complications were observed. The Synovis venous coupling device system allowed a time-efficient and safe venous anastomosis in breast reconstruction.
Since the first description of the technique (1, 2) free-flap surgery has become a routine procedure in breast reconstruction. Free-flap surgery frequently leads to patient satisfaction and can be executed fairly straight forwardly. Disadvantages are the requirement of microvascular anastomoses, with the need for adequate training, experience and equipment. Most free-flap failures result from technical problems in performing vascular anastomoses, such as endothelial intima lacerations, distortion of the vessels, and unequal intersuture distances. These incorrect practices can lead to thrombosis formation and, ultimately, flap failure (3). Microvascular surgical anastomosis remains one of the most technically sensitive aspects of free-tissue transfers. To facilitate these often time-consuming, difficult anastomoses, various anastomotic coupling systems have been introduced (4-7). The purpose of our report is to describe the usefulness of a coupler system, which is time-efficient and safe in performing venous anastomosis.
Patients and Methods
Between 12/2006 and 09/2007, 11 patients were treated, 8 with deep inferior epigastric perforator flap (DIEP), 2 with free transverse abdominal rectus muscle (TRAM) and 1 with free latissimus dorsi flap. Patients characteristics are listed in Table I. Two patients had had extensive ductal carcinoma in situ. One suffered from medullar carcinoma and five from ductal invasive carcinoma. Three patients had conversion due to implant Problems and one needed reconstruction after mastectomy only. For venous anastomosis, the Synovis venous coupling device (www.synovismicro.com) was used. The Microvascular Anastomotic COUPLER System is a mechanical method for small vessels ranging in size from 0.8 mm to 4.3 mm in outer diameter (Figure 1). It provides an intima-to-intima anastomosis, with no foreign material exposed to the flow surface. A successful anastomosis is performed in five steps: i) placement of the vascular clamp; ii) pinning of vessels to coupler; iii) rotation of the instrument knob to mate vessel ends; iv) forceps are used to ensure the fit is tight and v) intima-to-intima anastomosis is confirmed (Figure 1).
Results
Twelve anastomoses in eleven patients were performed with the coupler: 11 of them were venous and 1 was arterial. The recipient vessels were the mammaria interna vessels, except in one case in which the thoracica lateral vessels were used, particularly the artery. All cases were performed with a 2.0 mm to 2.5 mm coupler ring. Figure 1 shows the coupling procedure. There were no free-flap failures. Venous congestion occurred in only one case and was successfully managed with leeches. No major complications were observed. Figures 2, 3 and 4 shows different cases of successful free-flaps. At a median follow-up time of 19.6 months (range 13-27 months) there had been two deaths, due to progressive disease.
Discussion
Free-flap surgery has become a routine procedure in breast reconstruction. Coupler-assisted anastomoses are performed on both, arteries and veins. The overall success rate varies between 94% and 100% for venous (1, 4, 8-10) and between 87% and 100% for arterial anastomosis (11-13). Preferred recipient vessels are the thoracodorsal or internal mammary vessels. In their first eleven cases, Allen and Treece used the thoracodorsal vessels as recipient vessels (1). There was 100% flap survival in all patients, with only a small amount of flap necrosis in one patient. Arterial anastomosis complication rate varies between 3.2% (12) and 13% (11). The coupling system by Spector et al. was only used, if the thoracodorsal artery was the recipient, never in the internal mammary artery (11). Our single arterial anastomosis was done on the thoracodorsal artery as recipient. Elliot et al. used a coupling device for the venous anastomosis in their 3-hour muscle free flap, reported in 111 cases. The coupling device allowed a reduction in the time of the venous anastomosis from approximately 12 minutes to 3 minutes. There was no total flap necrosis in this series (10). As performed in our own series, Granzow et al. used an anastomostic coupling device to connect to the recipient and flap veins. Typically, the arterial anastomosis is performed with a nylon 9/0 suture (8). In this retrospective analysis on 758 DIEP flaps, 6% of patients returned to the operating room for flap-related problems. Partial flap loss occurred in 2.5% while total flap loss occurred in fewer than 1% of all cases. In a series of 117 patients, Knight et al. preferred the internal mammary artery as recipient, which was used in 65.3%. The rate of anastomotic revision (arterial and venous) was 4.9%. The majority of cases used a 2.5-mm venous coupler (65.3%) (14). In our series, the venous coupler used was between 2.0 mm and 2,5 mm. Yap et al. reviewed the microsurgical procedures performed at the M.D. Anderson Cancer Center over a 40-month period. In this retrospective analysis, they compared anastomostic coupling devices (ACD) and sutured anastomosis. Overall, the venous thrombosis rates were not significantly different between the ACD (1.4%, 2/139 cases) and sutured (3.3%, 19/584 cases) groups. Salvage rates following venous thrombosis were not significantly different for venous anastomoses performed with an ACD (50%, 1 of 2 cases salvaged) compared with venous anastomoses performed with sutures (68.4%, 13 of 19 cases salvaged) (15).
Patient characteristics.
In our series, there was one venous congestion, treated with leeches. Only one arterial anatomosis was performed on the thoracodorsal artery. There were no major complications.
The coupler system was time effective and safe in performing venous anastomosis in free-flap breast reconstruction.
a) Vessel measuring gauge; b,c) anastomotic instrument; d) successful intima-to-intima anastomosis both artery and vein.
Free latissimus dorsi flap, preoperative (a) and postoperative (b) view.
Free DIEP pre- (a) and postoperative (b) view.
Free DIEP pre- (a) and postoperative (b) view, after skin-sparing mastectomy and left and right mammaplasty.
Footnotes
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↵* Presented at the 8th International Conference of Anticancer Research, 17-22 October 2008, Kos, Greece.
- Received January 8, 2009.
- Revision received March 13, 2009.
- Accepted May 4, 2009.
- Copyright© 2009 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved
