A Unique Case of Venous Coupler Disruption and Salvage of Venous Anastomosis in a Case of Free Latissimus Dorsi Flap Reconstruction.

ABSTRACT

Free flaps are considered the gold standard for the reconstruction of various defects. Microvascular anastomosis is a very critical component of free flap surgery determining its success. The workhorse technique of hand suturing for microvascular anastomosis has consistently been used with excellent results. Recently, venous couplers are being increasingly used for performing venous anastomosis. We describe the case of a 14-year-old girl in which heel reconstruction was planned for an unstable scar and chronic osteomyelitis of the calcaneal region with a free latissimus dorsi muscle flap. Arterial anastomosis was done by hand suturing, while venous coupler (GEM coupler, Synovis Micro Companies Alliance) was used for venous anastomosis. Just before wound closure, the venous coupler spontaneously snapped open, resulting in disruption of the device and opening of the anastomosis. After securing hemostasis, the ring of the coupling device was tried to be removed, but it was adhered to the tunica externa due to the interlocking pins. Cutting the veins proximal to the rings would result in shortening of the vein with the requirement of a vein graft. The harvested latissimus dorsi muscle had a single vena comitans which had to be salvaged, so we improvised by everting the vein edges from the interlocking pins and completing the anastomosis by hand after freshening the margins. The interlocking rings were left as such in their place. Postoperative period was uneventful, and the flap survived with good results. Thus, this is a unique case where we report for the first time the disruption of a venous coupling device and subsequent salvage of free flap.