Quantitative assessment of intervortex anastomosis in central serous chorioretinopathy and fellow eyes: Does the size of anastomotic vessels matter for the diagnosis?

PURPOSE: To evaluate the frequency and size of intervortex anastomosis at the posterior pole on en-face spectral domain optical coherence tomography (SD-OCT) images in central serous chorioretinopathy (CSC) cases and their fellow eyes and its associations with choroidal morphology. METHODS: Sixty-five treatment-naive eyes of 65 patients with CSC, 65 fellow eyes, and 55 eyes of healthy age-matched participants were included. The presence of intervortex anastomosis at the watershed zone and asymmetry of the choroidal vessels between the superior and inferior macula were evaluated using 6 × 6 mm en-face SD-OCT. The diameter of the widest Haller vessel and the diameter of the widest anastomotic Haller vessel passing through the watershed zone were measured on en-face SD-OCT images. The choroidal vascularity index (CVI) was assessed using ImageJ software. RESULTS: Intervortex vein anastomosis on the horizontal watershed zone was detected in 75.4% diseased eyes, 61.5% in fellow eyes, and 36.4% in healthy age-matched controls (p < 0.001). The mean CVI was significantly higher in both diseased (74.3 ± 2.3%) and fellow (73.8 ± 2.2%) eyes of CSC cases than in healthy controls (72.5 ± 2.3%) (p = 0.002, p = 0.013, respectively). In the cases with intervortex vein anastomosis, the diameter of the widest anastomotic Haller vessel passing through the watershed zone was 0.40 ± 0.10 mm in diseased eyes, 0.35 ± 0.11 mm in fellow eyes, and 0.30 ± 0.09 mm in healthy age-matched controls (p = 0.001). CONCLUSIONS: Intervortex anastomosis might be seen as a variation in normal eyes, however, its frequency and the size of anastomotic vessels are significant higher in not only CSC but also in fellow eyes.

Limiting Levels of Fingertip Replantation Without Venous Anastomosis.

PURPOSE: This study aimed to compare the success rates of fingertip replantation with and without venous anastomosis. METHODS: This retrospective study included 132 patients with 148 fingertip injuries who had undergone fingertip replantation (Ishikawa's classification I‒IV) between 2003 and 2020 at our hospital. Among them, 117 and 15 were men and women respectively, and their mean age was 43 years. There were 53, 44, and 51 fingertips with Ishikawa subzone II, III, and IV amputations respectively, and no cases were classified as Ishikawa subzone I. Venous anastomosis was performed on 64 fingertips (group A). This was not possible in the remaining 84 fingertips; thus, an external bleeding method was used (group B). Our external bleeding protocol consisted of 4-hourly skin pricks of the distal pulp with a 23-gauge needle for the first 5 days. The analyses included survival rates, hemoglobin levels (Hb), and blood transfusions administered. RESULTS: The overall survival rate was 90.5% (134 of 148). In group A, survival was achieved in 92.3%, 100%, and 94.3% of those with subzones II, III, and IV amputations, respectively. In group B, survival was achieved in 100%, 82.1%, and 62.5% of those with subzones II, III, and IV, respectively. Subzone IV in group B showed a significantly lower rate of replantation success. In groups A and B, the preoperative and 7-day postoperative Hb levels were 14.5 g/dL and 14.6 g/dL, and 11.3 g/dL, and 11.6 g/dL, respectively. In addition, blood transfusion was required for five patients (7.9%) in group A and six patients (7.9%) in group B. Thus, the Hb levels and blood transfusion administered were similar between the two groups. CONCLUSIONS: Subzone IV is an important threshold for artery-only replantation. Furthermore, our external bleeding protocol is a safe and effective method. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Imaging Modalities for Evaluating Lymphedema.

Lymphedema is a progressive condition. Its therapy aims to reduce edema, prevent its progression, and provide psychosocial aid. Nonsurgical treatment in advanced stages is mostly insufficient. Therefore-in many cases-surgical procedures, such as to restore lymph flow or excise lymphedema tissues, are the only ways to improve patients' quality of life. Imaging modalities: Lymphoscintigraphy (LS), near-infrared fluorescent (NIRF) imaging-also termed indocyanine green (ICG) lymphography (ICG-L)-ultrasonography (US), magnetic resonance lymphangiography (MRL), computed tomography (CT), photoacoustic imaging (PAI), and optical coherence tomography (OCT) are standardized techniques, which can be utilized in lymphedema diagnosis, staging, treatment, and follow-up. Conclusions: The combined use of these imaging modalities and self-assessment questionnaires deliver objective parameters for choosing the most suitable surgical therapy and achieving the best possible postoperative outcome.

A Safe and Innovative Method to Apply Venous Coupler in Oncologic Head and Neck Reconstruction.

Venous anastomosis with a coupler device is an effective alternative to the hand-sewn anastomosis technique. Twist in the veins following a coupler anastomosis is a troublesome complication that needs a revision of venous anastomosis. The author proposes a simple technique to reduce the incidence of this complication. This technique is particularly useful in head and neck reconstruction and for beginners in the initial part of the learning curve.

A new insight into pachychoroid diseases: Remodeling of choroidal vasculature.

PURPOSE: Pachychoroid spectrum diseases are regarded as being different manifestations of a common pathogenic process. We suggest that pachychoroid diseases are consequences of chronic vortex vein stasis. METHODS: We describe how we came to this conclusion based on our own recent reports as well as a search of the related literature. RESULTS: Central serous chorioretinopathy (CSC) is the first stage of pachychoroid spectrum diseases. CSC is caused by congestion of choroidal veins, which are branches of the vortex veins. The venous outflow tract of the choroid is divided into four quadrants, based on horizontal and vertical watershed zones, with one or two vortex veins in each quadrant being independently responsible for venous outflow. In acute CSC, vortex vein stasis frequently causes asymmetric dilatation of the vortex veins in the horizontal watershed. The area of geographic filling delay in the choriocapillaris coincides with the area of this asymmetrically dilated vortex veins. With chronic stasis of the vortex veins, venous anastomosis occurs in the watershed zone as a means of compensating for the stasis, and the choriocapillaris becomes occluded in the area of filling delay. The anastomotic vessels dilate, becoming often hyperpermeable, and are then recognizable as pachyvessels. With the development of choriocapillaris ischemia, choroidal neovascularization (CNV) occurs at the site of pachyvessels. This is termed pachychoroid neovasculopathy (PNV). Polypoidal choroidal vasculopathy is regarded as a variant of PNV. CONCLUSIONS: Intervortex venous anastomosis is among the key factors underlying the development of pachychoroid diseases. Remodeling of the venous drainage route though the anastomosis across the watershed zones is apparently a common response to chronic vortex vein stasis.

Prevention of Secondary Lymphedema after Complete Lymph Node Dissection in Melanoma Patients: The Role of Preventive Multiple Lymphatic-Venous Anastomosis in Observational Era.

Background and Objectives: Current guidelines have limited the performance of complete lymph node dissection (CLND) for patients with clinically detectable lymphatic metastases. Despite the limitations of this surgical procedure, secondary lymphedema (SL) is an unsolved problem that affects approximately 20% of patients undergoing CLND. Preventive lymphatic-venous micro-anastomoses (PMLVA) has already demonstrated its efficacy in the prevention of SL in melanoma patients with a positive sentinel lymph node biopsy (SLNB), but the efficacy of this procedure is not demonstrated in patients with clinically detectable lymphatic metastases. Materials and Methods: This retrospective cohort study, was performed in two observation periods. Until March 2018, CLND was proposed to all subjects with positive-SLNB andPMLVA was performed in a subgroup of patients with risk factors for SL (Group 1). From April 2018, according to the modification of melanoma guidelines, all patients with detectable metastatic lymph nodes underwent PMLVA during CLND (Group 2). The frequency of lymphedema in subjects undergoing PMLVA was compared with the control group. Results: Database evaluation revealed 172 patients with melanoma of the trunk with follow-up information for at least 6 mounts. Twenty-three patients underwent PMLVA during CLND until March 2018, 29 from April 2018, and 120 subjects underwent CLND without any preventive surgery (control Group). The frequency of SL was significantly lower in both Group 1 (4.3% vs. 24.2%, p = 0.03) and Group 2 (3.5%, p = 0.01). Patients undergoing PMLVA showed a similar recurrence-free periods and overall survival when compared to the control group. Conclusions: PMLVA significantly reduces the frequency of SL both in immediate and delayed CLND. This procedure is safe and does not lead to an increase in length of hospitalization.

Dual Venous Drainage for the Free Latissimus Dorsi Muscle Flap-Using the Serratus Vein Tributary-Making Virtue of a Necessity.

Background Most flap failures in the lower limb are on account of venous congestion. Literature shows a decrease in the incidence of venous failure when two veins are anastomosed. The thoracodorsal pedicle of the latissimus dorsi free flap affords the possibility of a single venous anastomosis. The lack of a second venous outflow could result in venous congestion in the distal limits of the flap, particularly when long flaps are required for large defects or when the recipient veins are smaller in diameter. Methods We describe a consecutive series of 11 cases of latissimus dorsi flaps for leg and foot defects with a mean defect size of 310 cm 2 , where the serratus anterior vein was used as a second venous outflow channel to ensure maximal venous drainage. Results There were no re-explorations for anastomotic causes. Only one case had partial distal muscle necrosis. There was a delayed anastomotic blowout due to infection resulting in amputation in one case. There was no partial distal muscle necrosis in nine of the ten cases. Conclusion Using the serratus vein as a second venous outflow is of use in reducing incidence of venous occlusion and distal muscle necrosis and can be specially indicated for large flaps and venous diameter discrepancy.

Mechanical Anastomotic Coupling Device versus Hand-sewn Venous Anastomosis in Head and Neck Reconstruction-An Analysis of 1694 Venous Anastomoses.

Background There is a steep learning curve to attain a consistently good result in microvascular surgery. The venous anastomosis is a critical step in free-tissue transfer. The margin of error is less and the outcome depends on the surgeon's skill and technique. Mechanical anastomotic coupling device (MACD) has been proven to be an effective alternative to hand-sewn (HS) technique for venous anastomosis, as it requires lesser skill. However, its feasibility of application in emerging economy countries is yet to be established. Material and Method We retrospectively analyzed the data of patients who underwent free-tissue transfer for head and neck reconstruction between July 2015 and October 2020. Based on the technique used for the venous anastomosis, the patients were divided into an HS technique and MACD group. Patient characteristics and outcomes were measured. Result A total of 1694 venous anastomoses were performed during the study period. There were 966 patients in the HS technique group and 719 in the MACD group. There was no statistically significant difference between the two groups in terms of age, sex, prior radiotherapy, prior surgery, and comorbidities. Venous thrombosis was noted in 62 (6.4%) patients in the HS technique group and 7 (0.97%) in the MACD group ( p = 0.000). The mean time taken for venous anastomosis in the HS group was 17 ± 4 minutes, and in the MACD group, it was 5 ± 2 minutes ( p = 0.0001). Twenty-five (2.56%) patients in the HS group and 4 (0.55%) patients in MACD group had flap loss ( p = 0.001). Conclusion MACD is an effective alternative for HS technique for venous anastomosis. There is a significant reduction in anastomosis time, flap loss, and return to operation theater due to venous thrombosis. MACD reduces the surgeon's strain, especially in a high-volume center. Prospective randomized studies including economic analysis are required to prove the cost-effectiveness of coupler devices.

Comparable Patency of Open and Hybrid Treatment of Venous Anastomotic Lesions in Thrombosed Haemodialysis Grafts.

OBJECTIVE: Arteriovenous graft (AVG) failures are typically associated with venous anastomotic (VA) stenosis. Current evidence regarding AVG thrombosis management compares surgical with purely endovascular techniques; few studies have investigated the "hybrid" intervention that combines surgical balloon thrombectomy and endovascular angioplasty and/or stenting to address VA obstruction. This study aimed to describe outcomes after hybrid intervention compared with open revision (patch venoplasty or jump bypass) of the VA in thrombosed AVGs. METHODS: Retrospective cohort study. Consecutive patients with a thrombosed AVG who underwent thrombectomy between January 2014 and July 2018 were divided into open and hybrid groups based on VA intervention; patients who underwent purely endovascular thrombectomy were excluded. Patient demographics, previous access history, central vein patency, AVG anatomy, type of intervention, and follow up data were recorded. Kaplan-Meier curves were used to analyse time from thrombectomy to first re-intervention (primary patency) and time to abandonment (secondary patency). Cox regression analysis was performed to evaluate predictors of failure. RESULTS: This study included 97 patients (54 females) with 39 forearm, 47 upper arm, and 11 lower extremity AVGs. There were 34 open revisions (25 patches, nine jump bypasses) and 63 hybrid interventions, which included balloon angioplasty ± adjunctive procedures (15 stents, five cutting balloons). Technique selection was based on physician preference. Primary patency for the open and hybrid groups was 27.8% and 34.2%, respectively, at six months and 17.5% and 12.9%, respectively, at 12 months (p = .71). Secondary patency was 45.1% and 38.5% for open and hybrid treatment, respectively, at 12 months (p = .87). An existing VA stent was predictive of graft abandonment (hazard ratio 4.4, 95% confidence interval 1.2-16.0; p = .024). Open vs. hybrid intervention was not predictive of failure or abandonment. CONCLUSION: Hybrid interventions for thrombosed AVGs are not associated with worse patency at six and 12 months compared with open revision.

Right single lung transplantation using an inverted left donor lung: interposition of pericardial conduit for pulmonary venous anastomosis - a case report.

BACKGROUND: Lung transplantation (LTx) is still limited by the shortage of suitable donor lungs. Developing flexible surgical procedures can help to increase the chances of LTx by unfolding recipient-to-donor matching options based on the pre-existing organ allocation concept. We report a case in which a successful left-to-right inverted LTx was completed using the interposition of a pericardial conduit for pulmonary venous anastomosis. CASE PRESENTATION: A left lung graft was offered to a 59-year-old male who had idiopathic pulmonary fibrosis with predominant damage in the right lung. He had been prescribed bed rest with constant oxygen inhalation through an oxymizer pendant and had been on the waiting list for 20 months. Considering the condition of the patient (LAS 34.3) and the scarcity of domestic organ offers, the patient was highly likely to be incapable of tolerating any additional waiting time for another donor organ if he was unable to accept the presently reported offer of a left lung. Eventually, we decided to transplant the left donor lung into the right thorax of the recipient. Because of the anterior-posterior position gap of the hilar structures, the cuff lengths of the pulmonary veins had to be adjusted. The patient did not develop any anastomotic complications after the transplantation. CONCLUSIONS: A left-to-right inverted LTx is technically feasible using an autologous pericardial conduit for pulmonary venous anastomosis in selected cases. This technique provides the potential benefit of resolving challenging situations in which surgeons must deal with a patient's urgency and the logistical limitations of organ allocation.

Intraoperative identification and definition of "functional" lymphatic collecting vessels for supermicrosurgical lymphatico-venous anastomosis in treating lymphedema patients.

BACKGROUND: For current lymphatico-venous anastomosis (LVA), the identification of "functional" lymphatic collecting vessels (LCVs) is mainly based on indocyanine green (ICG) lymphography. However, some of the non-ICG enhanced LCVs utilized for LVA were found to have visual lymphatic flow. OBJECTIVES: Should non-ICG enhanced, but flow-positive LCVs be considered functional as well? METHODS: A retrospective study with 56 consecutive lymphedema patients (8 male/48 female) received LVA. LCVs were observed after ICG injection, before/after LVAs were performed. ICG enhancement and lymphatic flow in the LCVs were recorded and grouped as: Group A: all LCVs ICG(+) and flow(+); Group B: all LCVs ICG(+) and some were flow(+); Group C: some ICG(+) and some flow(+) LCVs; Group D: all LCVs ICG(-)but all flow(+); and Group E: all LCVs were both ICG(-) and flow(-). RESULTS: A total of 366 LCVs were identified, averaging 8.2 LVAs, 6.5 LCVs, and 4.7 veins per patient. A total of 33 LVAs were performed with 27 LCVs with no ICG enhancement from 7 patients (Group D). These patients were satisfied with their lymphedema improvements. CONCLUSION: Lymphatic flow-positive but non-ICG enhanced LCVs, should also be considered as functional, thereby maximizing the number of functional LCVs for LVA.

MR lymphography in patients with upper limb lymphedema: The GPS for feasibility and surgical planning for lympho-venous bypass.

BACKGROUND AND OBJECTIVES: Lymphedema is caused by insufficient lymphatic drainage leading to abnormal accumulation of interstitial fluid within soft tissues. Lympho-venous anastomosis (LVA), as a surgical option for selected patients, is widely applied. Through preoperative localization of functional lymphatics with indocyanine green, real time visualization of functioning lymphatic vessels is possible. This examination is time consuming and operator dependant and is not suitable to differentiate the ratio of fat hypertrophy to liquid edema. We investigated whether MR lymphangiography is accurate for imaging functional lymphatics and adjacent veins in arms. Furthermore, we investigated the accuracy and predictability of preoperative mapping for the feasibility of performing LVA and the preoperative decision making in lymphedema surgery. METHODS: A prospective study was performed in which 25 patients suffering from lymphedema of the upper extremity were examined. MR lymphography with contrast agent injection in a deep dermal plane was performed. RESULTS: Precise localization of lymphatic vessels crossing a vein was achieved in 18 of 25 arms. In 16 of the 18 patients in whom functional lymphatics were localized with an adjacent vein on MRI an LVA was performed successfully. CONCLUSIONS: MR lymphangiography is an accurate and reproducible method for imaging and mapping of lymphatic channels in the lymphedemateous limb.

Lymphatic-venous anastomosis in a rat model: A novel exercise for microsurgical training.

BACKGROUND AND OBJECTIVES: Lymphedema is a condition of localized fluid retention and tissue swelling caused by a compromised lymphatic system. Lymphaticovenular anastomoses (LVA) and multiple lymphatic-venous anastomoses (MLVAs) have been recognized as efficient methods to treat chronic lymphedema. Because few models for lymphatics microsurgical training have been described, the aim of this study is to present a new training model for MLVA in a rat. METHODS: Ten norvegicus rats were used for this study. After a longitudinal xifo-pubic incision, lumbar nodes were injected with blue patent violet (BPV) to identify from two to four lymphatic vessels (LVs). MLVAs were carried out inserting lymphatics into the right lumbar vein. RESULTS: The mean weight of the rats was 511.4 g. The average diameter of the abdominal LVs used for MLVA was 0.26 mm, and the mean size of the right lumbar vein was 0.84 mm. The average time to perform MLVA was 49.8 minutes. Anastomosis patency rate was 70% based on the passage of BPV from the lymphatics into the vein. CONCLUSIONS: The rat is still a feasible resource to train microsurgeons, and the MLVA model proposed is simple and reliable and could be very useful for microsurgeon training.

[Use of indocyanine green angiography in oncological and reconstructive breast surgery]. / Utilisation du vert d'indocyanine en chirurgie sénologique et reconstruction mammaire.

The Indocyanine green (ICG) is a soluble dye that is eliminated by the liver and excreted in bile. When illuminated by an near-infrared light, the ICG emits fluorescence in the near-infrared spectrum, which can be captured by a near-infrared camera-handled device. In case of intravenous injection, ICG may be used as a marker of skin perfusion. In case of interstitial injection, it may be useful for lymphatic network mapping. In oncological and reconstructive breast surgery, ICG is used for sentinel lymph node identification, to predict mastectomy skin flap necrosis, to assess the perfusion of free flaps in autologous reconstruction and for diagnosis and treatment of upper limb secondary lymphedema. Intraoperative indocyanine green fluorescence might also be used to guide the excision of nonpalpable breast cancer.

Lymphatico-venous anastomosis as treatment for breast cancer-related lymphedema: a prospective study on quality of life.

PURPOSE: Lymphedema is a chronic and disabling sequel of breast cancer treatment that can be treated by lymphatico-venous anastomosis (LVA). Artificial connections between the venous and lymphatic system are performed supermicrosurgically. This prospective study analyses the effect of LVA on quality of life. METHODS: A prospective study was performed between November 2015 and July 2016 on consecutive patients in the Maastricht University Medical Centre. Quality of life was considered as the primary outcome, and the Lymphedema International Classification of Functioning (Lymph-ICF) questionnaire was used. Discontinuation of compressive stockings and arm volume, using the Upper Extremity Lymphedema index (UEL-index), were the secondary outcomes. RESULTS: Twenty women with early-stage breast cancer-related lymphedema (BCRL) were included. The mean age was 55.9 ± 4 years and the median BMI was 25.1 [21-30] kg/m2. The mean follow-up was 7.8 ± 1.5 months. Statistically significant improvement in quality of life was achieved in the total score and for all the quality of life domains after one year of follow-up (p < 0.05). The discontinuation rate in compressive stockings use was 85%. The difference in mean relative volume did not show a statistically significant decrease. CONCLUSIONS: LVA for early-stage BCRL resulted in a significant improvement in quality of life and a high rate in stocking discontinuation.

Venous anastomosis using a non-penetrating vascular closure system in orthotopic liver transplantation.

BACKGROUND: A non-penetrating vessel closure system (VCS-AnastoClip® ) may facilitate vascular anastomosis. The purpose of this study is to explore the utilization of a non-penetrating VCS in orthotopic liver transplantation (OLT). METHODS: From January 2015 to February 2017, patients who underwent OLT were divided into two groups, ie, those who underwent non-penetrating VCS application for inferior vena cava (IVC) and portal vein (PV) reconstructions and those who underwent hand sewing for these purposes. Clinical data, venous anastomotic times, anhepatic phases, and the recovery of liver function were compared between the groups. RESULTS: One hundred and fifteen patients underwent OLT (63 in the VCS group and 52 in the suture group). No differences between the two groups were observed in the baseline characteristics. The venous anastomotic time and anhepatic phase in the VCS group were significantly shorter than those in the suture group (P < .01). The alanine transaminase and total bilirubin levels in the VCS group were comparable to those in the suture group (P = .39 and P = .06, respectively). The complication, mortality, and patency rates of the PV reconstructions did not differ significantly between the two groups. CONCLUSIONS: In OLT, the reconstruction of the PV and IVC with a non-penetrating VCS system is a safe alternative method that has the advantage of shortening the anastomotic time and the anhepatic phase compared to the results of conventional hand suturing. However, the use of this VCS system had no influence on the recovery of graft function.

[Liposuction combined with lymphatico-venous anastomosis for treatment of secondary lymphedema of the lower limbs: a report of 49 cases].

Objective: To study the clinical effects of liposuction combined with lymphatico-venous anastomosis for treatment of secondary lymphedema of the lower limbs. Methods: A retrospective analysis was performed for 49 patients who had undergone liposuction combined with lymphatico-venous anastomosis to treat secondary lymphedema of the lower limbs at Department of Lymph Surgery, Beijing Shijitan Hospital from November 2013 to February 2015.All patients were female aging from 31 to 70 years with median age of (52±10)years.All patients had history of pelvic surgery.There were 32 cases with cervical carcinoma, 11 cases with endometrial cancer, 1 case with ovarian cancer who accepted radical hysterectomy, 2 cases with benign tumor who accepted resection, 2 cases accepted inguinal lymph node dissection, 1 case with rectal cancer accepted radical resection.There were 30 cases with history of radiation therapy and 23 cases with history of erysipelas recurrent((2.1±3.9)/year). The limb swelling degree in preoperative and postoperative patients was explored using one-way analysis of variance with replicate measures and paired sample t-test. Meanwhile the incidence of lymphogenous infection was used as an evaluation of operation efficacy. Results: The mean lower limb circumference difference at 7 days, 6 months and 12 months was (0.17±1.36)cm, (1.25±1.62)cm and(1.58±1.56)cm, respectively, which was significantly decreased compared with preoperative((4.92±2.16)cm) (t=-5.712, -5.777, -5.765; all P<0.01). The mean lower limb volume difference at 7 days, 6 months and 12 months was (522±799)ml, (726±973)ml and (889±895)ml, respectively, which was significantly decreased compared with preoperative((2 729±1 335) ml)(t=-5.905, -6.093, -5.777; all P<0.01). The incidence of erysipelas was 0.0(0.0, 0.0)/6 months within 6 months after operation and 0.0(0.0, 0.0)/6 months within 6-12 months after operation, which was significantly lower than that before operation(0.0(0.0, 2.0)/year). The feeling of tightness and heaviness of the limb was significantly improved compared with preoperative. Conclusion: Liposuction combined with lymphatico-venous anastomosis is an effective method for the treatment of secondary lymphedema of the lower limbs.

Dual venous outflow improves lower extremity trauma free flap reconstructions.

BACKGROUND: Venous outflow problems are the most common reasons for perioperative flap complications. The benefit of a second venous anastomosis, however, remains unclear in lower extremity trauma free flap reconstruction and warrants further investigation. MATERIALS AND METHODS: Retrospective review of our institutional flap registry from 1979 to 2014 identified 464 free flaps performed for lower leg trauma reconstruction. Patient demographics, flap characteristics, and outcomes were examined. RESULTS: A total of 219 flaps were randomly selected for preliminary analysis. Single-vein outflow was more common (72.6%) than dual-vein (27.4%); most of the recipients were in deep venous system (83.6%) versus superficial (11.9%) or both (4.6%). Two-vein anastomoses were more likely in fasciocutaneous flaps than muscle flaps (P = 0.001) and in smaller (<300 cm(2)) flaps (P = 0.002). Complications occurred in 98 flaps (44.7%); with 54 partial flap losses (24.7%), and 11 complete flap losses (5.0%). Multivariable regression analysis controlling for age, sex, flap type, presence of bone gap, flap size, vein size mismatch, and time since injury demonstrated dual-vein outflow to be protective against complications (relative risk [RR] = 0.269, P = 0.001), partial flap failure (RR = 0.351, P = 0.031), and any flap failure (RR = 0.31, P = 0.010). No significant difference in operative time was found (P = 0.664). CONCLUSIONS: Dual-vein outflow demonstrated 73% reduction in overall complications and 69% reduction in flap failure rate compared to single-vein flaps. These results suggest a protective effect of a dual-vein outflow system, and when considered together with our findings of unchanged operative time, provide evidence for preferential use of two venous anastomoses when possible for free flap reconstruction of lower extremity trauma.

Methods in renal research: kidney transplantation in the rat.

Kidney transplantation in small animals has been crucial in the development of anti-rejection therapies. While there is no substitute for a skilled microsurgeon, there are many aspects of the transplant procedure that can be modified to optimize the reproducibility and utility of the technique. This article provides a detailed description, including video recording, of orthotopic kidney transplantation in the rat. The key variables in the technique are also discussed.

Safety and reliability of the internal jugular vein for venous anastomoses in head and neck oncological reconstruction: A retrospective study.

This study aimed to assess the efficacy of utilizing the internal jugular vein (IJV) as the primary recipient site for venous anastomoses in head and neck oncological reconstruction. Patients who underwent a free flap reconstruction of the head and neck were retrospectively included. Venous anastomoses were preferentially performed less than 1 cm from the IJV, either end-to-side (EtS) on the IJV, or end-to-end (EtE) on the origin of the thyrolingofacial venous (TLF) trunk. When the pedicle length was insufficient to reach the IJV, anastomoses were performed EtE to a size-matched cervical vein. Of the 246 venous anastomoses, 216 (87.8%) were performed less than 1 cm from the IJV, including 150 EtS on the IJV (61.0%), and 66 EtE on the TLF trunk (26.8%). Thirty veins (12.1%) were anastomosed EtE on other cervical veins more than 1 cm from the IJV. Two venous thromboses occurred (0.9%) and were successfully managed after revision surgery. There was no evidence of an increased thrombosis rate in high-risk or pre-irradiated patients. These findings suggest that the internal jugular vein is safe and reliable as a first-choice recipient vessel for free flap transfers in head and neck oncological reconstruction.