VASCULARREPAIR

BasicTechniques
EssentialsforaPatentAnastomosis
Oncetheanimalhasbeenpreparedandthevascularstructureshavebeenexposed,the
microscopeisthenpositioned.Thereareseveralessentialrequirementstoensurean
anastomosiswithlongtermpatency,whetherinthelaboratoryorclinicalsituation:
1. Atraumaticdissectionandhandlingofthevesselmustbemeticulous,withtying
orbipolarcoagulationofbranchesasnecessary.
2. Thevesselwallandintimaatthesiteofanastomosismustbenormalwhen
visualizedunderhighpowermagnification;ifnot,itisimperativethatthevessel
beresectedbacktonormaltissue.
3. Adequateflowmustthenbedemonstratedfromtheproximalpartofthevessel.
4. Theanastomosismustbeperformedwithouttension,andvesselmobilizationor
graftingmaybeneededtoensureatensionfreeanastomosis.Theincidenceof
earlyandlatefailureisincreasedbytensionontheanastomosis.
5. Meticulousattentiontodetailisrequiredincompletingtheanastomosis.Adequate
removaloflocaloverhangingadventitia(whichisintenselythrombogenic),
followedbysutureplacement,withoutgraspingtheintima,toproduceanearly
leakproofanastomosisisrequired.Themostcommontechnicalerroris
inadvertentsuturingofthebackwall,andthismaybepreventedbyseveral
techniquesdescribedlaterinthischapter.

EndtoEndAnastomosisTechnique
Oncethevesselhasbeenpreparedandadequateproximalflowensured,theanastomosis
isperformed.Makingsurethatthereisadequateflowfromtheproximalendofthevessel
isessentialtopreventthrombosis,andthestepofremovingtheclampandvisualizing
outflowfromthisvesselisoftenoverlookedbyinexperiencedmicrosurgeons.Likewise,
overzealouscleaningofadventitiaistobeavoidedbecausethisweakensthevesselat
theanastomoticsiteandcanleadtofalseaneurysmformation.Onlyenoughadventitia
shouldberemovedsothatitisnotanimpedimenttosuturingthevesselandcannotget
caughtinthelumen.Ifproximalflowisimpaired,gentledilationwithalacrimaldilator
andapplicationoflocalvasodilatingagents(lidocaineandthelike)mayimproveflow.
Allowingthevesselstorestundisturbedforseveralminutesandwarmingthetissuemay
alsoaidindecreasingspasm.Thebasicanastomosisproceduredescribednextisa
summationofthetechniquesmostwidelyrecommendedbyseveralnotedauthors.

figure47.12
Theclampsareadjustedsothatnotensionisplacedontheanastomosissite(Figure
47.12AtoC).Thearteryisdividedcleanly,andtheadventitiaistrimmed(seeFig.
44.12DtoF).Thelumenisgentlydilated(seeFigure47.12GandH).Overzealous
dilationistobeavoidedbecauseitcandamagethefragilevesselwall.Thevesselisnow
readyforanastomosis(Figure47.13).Onlytheadventitiaispickedupintheforceps,and
thesuturesareplacedatraumatically.Intraluminalcounterpressurewiththeforcepsis
useful,buttheintimaandvesseledgeshouldneverbegraspedwiththeforceps.

figure47.14

Cornersutures120to180degreesapart(Figure47.14A)areplacedfirst.Inarteries,the
suturebiteshouldbeonetotwotimesthethicknessofthevesselwall.Inveins,awidth
oftwotothreetimesthewallthicknessisused(Figure47.15A).Oneofthemost
commonmistakesmadeintheearlystagesistoapproachthevesselwallwiththeneedle
tipparalleltothewall.Iftheneedleisplacedwiththetangentofthetipoftheneedleat
anythinglessthan90degreestothevesselwall,inversionwithexposureofthe
adventitialsurfacetotheflowofbloodmayresult.Althoughproperneedleplacementis
awkwardatfirst,theneedleshouldberotatedbackwardwiththeneedleholdertoensure
thatthesutureevertsthevesselwallratherthaninvertsit(Figure47.16).

figure47.15

figure47.16
Oneimportantfactorinavoidingleaksistominimizetraumatothevesselwallfrom
placingtheneedle.Forthisreason,thenoviceshouldrememberthattheneedleiscurved
andnotstraight(inmostinstances).Therefore,theneedleshouldbepulledthroughthe
vesselwallfollowingthearcoftheneedletoavoidtraumatothewall.Pullingthelast
halfoftheneedlethroughinastraightmotiontearsthevesselwallandcreatesalarger,
obliqueholeratherthanaclean,roundone.Asthesutureispulledthroughthevessel
wall,careshouldbetakentoguidetheleadingandfollowingsuturewiththeinstruments
sothatthesutureispulledsmoothlythroughthevesselwall.Sutureforciblypulled
throughthewallagainstresistancewilltendtocutthroughandresultinendothelial
damage.Iprefertouseasurgeonsknotforthefirstthrow,butthesutureshouldbe
gentlytighteneduntilthevesselwallsjustmeet.Overtighteningthesuturewillinvertor
tearthevesselwallandtherebyexposethrombogenicsurfacestothelumen.
Overtighteningalsoresultsindirectnarrowingofthelumenasthetissueisdistorted.A
squareknotandthirdthrowarethencompleted,againavoidingovertightening.
Therearetwooptionsforretrievingtheneedle.First,itmaybecarefullyplacedinthe
fieldofviewbeforetyingtheknotandthenpickedupforthenextstitch.Thesecond
methodistopulltheneedleandattachedsutureoutofthefield,tietheknot,cutthe
suture,andthenpullonthetrailingendwhileguidingthesuturewithforcepstoretrieve
theneedle.Ipreferthelattermethodbecauselesssuturematerialispresentinthefieldto
interferewithtyingtheknot.Thesurgeonmustalwaysholdthesuturenearthevessel
withforcepswhenreleasingtheneedlefromtheneedleholder.Ifnotdone,theneedleor
suturemaysticktotheinstrumentandbepulledoutofthevessel.
Oneormoresuturesarethenplacedbetweenthecornersutures.Thelastsutureplacedin

eitherthefrontorthebackwalliscriticalbecauseitisdifficulttovisualizethelumenand
preventinadvertentsuturingoftheoppositewall.Ifthecornersuturesareplaced120
degreesapart,thebackwallwilltendtofallawayandthusbeprotected(asymmetric
biangulationtechnique).82Thevesselisthenrotated180degreesbyflippingthevessel
clamporpreviouslyplacedcornersutures.Thebackwallisthensutured,andaseach
sutureisplaced,thelumenisirrigatedandgentlydilatedwithforcepstoensurethatthe
backwallisnotcaughtupinoneofthesutures.
Placementofthefinalsutureiscritical,andseveraltechniquescanbeusedtoavoid
suturingtheoppositewall.
1.Theneighboringtwosuturescanbeleftlong,andtractioncanbeplacedonthemto
isolatetheinterveningvesselwallforplacementofthefinalsuture.
2.Oneofthesuturesonthewalloppositethefinalsuturecanbegraspedtopullthefar
wallawayfromthefinalsuture.
3.Theneedlecanbepassedthroughonesideoftheanastomosis,broughtoutthrough
thedefect,andthenusedtogentlypickupandeverttheadjacentwallasitisplaced.
4. Atwosuturetechniquecanbeusedinwhichthefirstneedleispassedthrough
bothsidesbutnotpulledthrough.Thesecondstitchisthenplacedandtied,and
thefirstsutureisthenpulledthroughandtied.
5. AmodificationoftheHarashinaprocedureisoftenveryuseful(Figure47.17).35
Thelasttwosuturesareplacedasthoughonewereperformingacontinuous
runningsuture.Theloopbetweenthesuturesisleftlargeinsteadofbeing
tighteneddownandisthencutwiththesuturescissors;thetwoendsareleftin
placeandarereadyfortying.Thisconservessutureandmotionandminimizesthe
numberofneedles,instruments,andsuturesintheoperativefield.Itmayalsobe
thebestalternativeforamicrosurgeonworkingalone.
Theclampisthenreleased,andflowisobservedunderthemicroscope.Oozingfromthe
anastomosisisnormal,butpulsatilebleedingmustbecontrolledbyplacingadditional
sutures.Itisusuallybesttoavoidoversewingavesselwithtoomanysuturesbecause
thiscanleadtotheplacementofmultiplebackwallsutures.Probablythesafestwayto
avoidsuturingthebackwallistoplacesuturesinquestionableareasafterthevesselis
fullofblood.Thismustbedoneexpeditiously,however,becauseplateletthrombican
formrapidlyatthesiteofsignificantleaksandmaypropagatewithinthelumen.Brisk
flowusuallyoccursthroughawellperformedanastomosis,butoccasionallyvessel
spasmseverelylimitsflow.Ifthisappearstobethecase,applylocalvasodilatingagents,
warmtheareaifpossible,andavoidmanipulatingthevesselfor15to20minutes.Any
anastomosisthatfailstoopenupwithinseveralminutesaftertheapplicationof
vasodilatorsandleavingitaloneshouldprobablyberevised,however.

PatencyTest

Assessmentofanastomoticpatencymaybedoneinseveralways.1,24Inclinicalsituations,
returnofcolortoandcapillaryoozingorvenousbleedingfromtherevascularizedtissue
signalacompetentarterialanastomosis.Ifthetissuebecomesengorgedafteraperiodof
arterialflow,theveinmaybeoccluded.Directinspectionofbotharterialandvenous
anastomosesunderthemicroscopemayrevealsignsofpatency.Arterialpatencyis
indicatedbynicelydilatedvesselsshowingpulsatileelongation(wriggling)or
expansilepulsation.Gentlyliftingthevesseldistaltotheanastomosisbyplacingforceps
underneathitwilldemonstratetheflickerofbloodflowingacrossthisarea,butitis
easilyvisibleonlyinthinwalledvessels.

Theemptyandrefillpatencytestistraumaticandshouldbeperformedasgentlyand
infrequentlyaspossible.40Twopairofsmoothforcepsareusedtooccludethevessel
distaltotheanastomosis.Themoredownstreamforcepsisthenmovedgently
approximately1cmdownthevesseltocreateanemptysegmentbetweenthetwo
forceps.Theproximalcompressionisthenreleased,andrapidfillingoftheempty
segmentindicatespatencyoftheanastomosis.Thistestisusefulforeitherarteriesor
veinsandforanysizeofvessel(Figure47.18).

Veins
Ratveinanastomosisisverydifficultbecause(1)thesevesselsareextremelyfriableand
thinwalled,(2)itisdifficulttoseparatetheadventitiafromthevesselwithoutdamage,
and(3)thelumentendstocollapse.Performingtheanastomosisunderfluidorwith
copiousirrigationtofloatthelumenopenisoftennecessary.Clampstendtotearthe
veinandmustbeusedwithextremecareornotatall(Figure47.19).Fortunately,the
veinsencounteredinreplantationandfreetissuetransferinhumansaremoresubstantial,
buttheystillretainsomeofthecharacteristicspreviouslymentionedandrequiremore
carefulhandlingandadditionalsuturestopreventintraluminalcollapseofsegmentsof
thevesselwall.

Tremor
Tremorisaproblemwithallmicrosurgery.Veryfewsurgeonsarefreeoftremor,but
mostgoodmicrosurgeonscancontrolit.Onemustmakesurethatthehandsandarmsare
supportedandthattheshouldersarerelaxedtodecreasetremor.Thelatherestprinciple
ofsupportingoneinstrumentwiththeotherisoftenusefultocontroltremorifthisisa
problem.Thefrustrationthatcanbeexperiencedindealingwithfinesutureandtenacious
tissuesinvivodefiesdescription.Aclandhasaddressedthehandlingofsuturematerialin
thesecircumstances,andhisarticleisrequiredreadingformicrosurgeonswhowishto
minimizetheirfrustration.2

CLINICALMICROVASCULARTECHNIQUES
Theabilitytoperformatechnicallyadequatevesselanastomosisinthelaboratorydoes
notguaranteesuccessinclinicalsituationssuchasreplantationandfreetissuetransfer.
Manyotherfactorsmayinfluencetheeventualoutcome,andthesurgeonwillneedto
favorablyinfluenceasmanyofthesefactorsaspossible(Table47.1).Thissectionand
thefollowingoneonphysiologyandpharmacologyaddresstheseproblems.

VesselCharacteristics,Access,andSizeDiscrepancy
Manydifficultiesmaybeencounteredinmovingfromatotallycontrolledlaboratory
settingtoaclinicalsituation,includingthefollowing:
1.
2.
3.
4.
5.

Difficultyorientingthevesselsforeaseofanastomosis
Limitedaccesstothevesselsinadeepwound
Vesselsizediscrepancy
Inabilitytorotatetheclampholdingthevesselforsuturingthebackwall
Difficultybecomingcomfortableinapositionappropriatetosuturethevessels

Itisfrequentlyimpossibletosignificantlychangethephysicalcharacteristicsofthe
vessels.Inanticipationofsuchsituations,oneshouldpracticeanastomosesinthe
laboratorywiththevesselsorientedatvariousanglesbetweenhorizontalandvertical.
Theimportantfactorinsuturingvesselsindifferentorientationsistoremembertomove
thepositionofyourhandstoallowprecisesutureplacement.Sometimesonesentirearm
positionmustbechangedtoappropriatelyplacethesuture,butawkwardhandpositioning
canleadtodamagingthevessel,andsurgeonsmustbecomfortableenoughwiththeir
techniquetosewwiththehandsintheproperrelationshiptothevessel.
Theuseofhumanretractionistobeavoidedwheneverpossiblewhilesuturingvessels
ornervesunderthemicroscope.Itishardenoughtosewvesselsinsomesituations
withouttheaddeddistractionofanassistantholdingaretractorandconstantlymoving.
Exposureisparamount,andoneshouldendeavortogainsufficientaccesssothatself
retainingretractorsareadequatetomaintainthefieldofview.Insomesituations,direct
accesstotheinjuredvesselsmaybenearlyimpossible.Aprimeexampleofthisproblem
occursinthumbrevascularizationorreplantation.Toapproachthevolarvesselsinthe
thumb,theforearmmustbeseverelypronatedorsupinated,anditisextremelydifficultto
maintainthispositionandperformtheanastomosis.Insuchasituation,analternative
approachsuchasgraftingofthevolarvesselsbeforebonefixationorinterpositionalvein
graftingtoamoreaccessibledorsalvessel(e.g.,theradialartery)shouldbeconsidered.
Thistypeofproblemisanexampleinwhichexperienceisessentialtoavoidfrustration.
Limitedaccesstodeeplyplacedstructuresmaybeimprovedbyextensionofthesurgical
incisiontoprovideamoreopenwoundorbyplacingmoistspongesbeneaththevessels
andliftingthemoutofthewound.Alternativeanastomosistechniques(endtosideor
backwallfirst)maybeusefulinthissituation.

VesselSizeDiscrepancy
Severalsolutionshavebeenproposedforvesselsizediscrepancy.Adifferenceof2:1or
lessmaybehandledbygentlydilatingthesmallervesselandnotdilatingthelargerone.
Withadifferenceofgreaterthan2:1,however,alternativetechniquesarepreferred.Vein
graftsaremoredistensiblethanarteriesandareveryusefulformatchingvesselsof
varyingdiameter.Itshouldbenoted,however,thatsuccessfulanastomosesbetween
arteriesandveingraftswithdiscrepanciesindiameterofupto5:1havebeenreported
experimentallywith96%patencyrates.97Theprimarymessagefromthisstudyistoplace
enoughsuturesaccuratelytobringthetwoendsintoperfectapproximation.
Endinendandspatulationtechniqueshavebeendescribedfordifferencesinsizeofup
to3:1.37,109,115Ifthesmallervesselemptiesintothelargerone,thesmallerendmaybe
telescopedinsidethelargervessel(endinendorsleevetechnique).Thisissafestifflow
proceedsfromthesmallervesselintothelargerone.Cuttingoneorbothvesselwalls
longitudinallyandrepairbytriangulatingthecorners,asisoftenusedbyvascular
surgeons,maybehelpful(spatulationtechnique).Cuttingthevesselendsobliquelyat
varyinganglesmayalsobeusedtochangetheeffectivediameter.9Anothertechnique
involvesspatulationofbothvesselendsandthensuturingthemtogetherwithonlyfour
suturesatthecorners.Theauthorsreportacceptablepatencyrateswiththistechnique.111
Arecentstudyevaluatedarterialflowpatternsandwallshearstresswithvarioustypesof
maneuverstoaccomplishanastomosisofvesselsofunequaldiameter.Althoughshear
stresswassimilarinalltypesofanastomosis,itwasnotedthatflowcharacteristicswere
best(leastturbulenceandflowseparation)whenawedgewasresectedfromthesmaller
vesseltoaccommodatethelargerone.94
Althoughnotnecessaryinthemajorityofcases,anaccomplishedmicrosurgeonshould
befamiliarwiththeuseofthesetechniquesifalargediscrepancyisencountered.
Encounteringavesselsizemismatchismorelikelyinthecaseoffreetransferthanwith
replantationorrevascularization.Oneshouldalsorememberthatendtosideanastomosis
canbeusedforvirtuallyanysizediscrepancyproblem.Whenusinganyofthese
techniques,itmustberememberedthatanyrapidchangeinsizeordirectionofthevessel
willproduceturbulenceandincreasethechanceforthrombosis.
Excessivetensionatthesuturelineisacommoncauseofbothimmediateanddelayed
anastomoticfailure.Thesurgeonshouldanticipatethisproblemanduseaninterpositional
veingraftratherthanattemptanendtoendanastomosisthatisundertension.This
techniqueisaddressedmorefullyinthesectiononveingrafting.Likewise,twistingof
thevesselatornearthesiteofanastomosiscanleadtothrombosis.Eventhough
experimentalworkshowsthatasmallamountoftwistdoesnotleadtoanincreased
thrombosisrate,49thesurgeonshouldmakeeveryefforttopreventtwistingofthevessel
atorneartheanastomosis.

AlternativeAnastomosisTechniques
Fouralternativetechniquesarefrequentlyusedclinicallyinsituationsinwhichthe
characteristicsofthevesselsarenotoptimalforstandardendtoendanastomosis:(1)
backwallfirsttechnique,(2)flippingofamobilevessel,(3)180degreevertical
technique,and(4)endtosidetechnique.

BACKWALLFIRSTTECHNIQUE(ONEWAYUPTECHNIQUE)
Thebackwallfirsttechnique,alsoknownastheonewayuptechnique,ismostuseful
withvesselsofapproximatelyequalsizewhenoneorbothendscannotberotatedwithin
adoubleclamp.Thismostcommonlyoccurswhentherepairismadeclosetoaparent
trunkorlargebranchthatcannotbesacrificed.Iactuallypreferthistechniqueformost
anastomosesbecauseIthinkthatdoubleclampsgetintheway.Withsomepractice,this
freehandanastomosisisnotdifficultandhastheaddedadvantagethatoneisnotlikely
tosuturebothwallstogether.

Fig.47.20
Inperforminganyanastomosis,themostdifficultsutureshouldalwaysbeplacedfirst,
andsoIprefertobegintheanastomosisontheposteriorwallatthepointfarthestaway

fromthesurgeon.Interruptedsuturesareplacedsequentiallytowardthesurgeonuntilthe
backwalliscompleted,andthenthefrontwallisrepaired.Theknotsare,ofcourse,
placedoutsidethelumen.Theinitialsutureisleftlongtoaidintractionandrotationof
thevessel(Figure47.20).Backwallfirstrepaircanalsobedonebyaddingsutures
alternatelytoeithersideofthefirstsutureuntiltheanastomosisiscompleted.43,117This
techniqueisarguablyoneofthesafestbecausetheentireinsideoftheanastomosiscanbe
visualizeduntiltheverylastfewsuturesareplaced.

FlippingTechnique
Inmanysituations,onevesselendisfreelymobileandcanbeflippedendoverendto
repairthebackwall.Examplesare
1. Veingrafting,wherethefirstanastomosiscanbecompletedinthismannerand
thesecondbystandardtechnique.
2. Freetissuetransfer,wheretheflapmaybefreelymobileifitisrevascularized
beforeinsetting.Extremecaremustbeusedwhenhandlingandinsettingtheflap
toavoiddamagetotheanastomosisbytensionorkinkingofthepediclewhen
usingthistechnique.
Thistechniqueisusefulwhenavesselabouttoundergoanastomosishasfeaturesthat
makedoubleclampplacementandrotationdifficult.Ihavefoundtheflippingtechnique
usefulforveingraftinginpatientswithretrocarpalthrombosisoftheradialartery,73
wherethedistalanastomosisisdoneonavesselorientedenduptowardthesurgeon
betweenthetwoheadsofthefirstdorsalinterosseous.Asingleclampisplacedonthe
distalvesselandtheveingraft,andthefrontwalliscompleted(Figure47.21A).Thevein
graftisthenflippedendoverendandthebackwallrepaired(seeFigure47.21BandC).

fig47.21
180DegreeVerticalTechnique
Inamodificationofthestandardapproach,thefirsttwosuturesareplaced180degrees
apartratherthanthestandard120degrees.Althoughthistechniquecontradictsthe
traditionalapproachofvascularsurgeons(i.e.,thetriangulationtechnique),itis
favoredbymanyexperiencedmicrosurgeons,particularlyinJapan.36,44Thisisoneofmy
favoredapproachesbecauseitallowsturningthevesselevenifthereislittleroomfor
suchamaneuverinthefield.Inthisapproach,thefirstsutureisplaceddirectlyopposite
thesurgeon,inthemidportionofthebackwallsofthevesselsbeinganastomosed.The
secondsutureisthenplaced180degreesfromthefirstsutureinthemidportionofthe
frontwall.Thesetwosuturesarecutlong,andtheycanthenbeusedtoturnthevessel90
degreesineitherdirectiontofacilitateplacementoftheremainingsutures(Figure47.22).

fig47.22

EndtoSideTechnique
Theendtosidetechniqueisastandardprocedurethatistaughtinallmicrosurgical
laboratorycoursesandhasbeenstudiedexperimentally.6,81Ifonlyasinglevessel
maintainstheviabilityofanextremity,itcannotbesacrificedasthedonorvesselforan
endtoendanastomosis,andanendtosiderepairmustbeused.Thismethodisalso
usefulifthereisalargesizediscrepancybetweenthevesselstobeanastomosed.Some
believethatthistechniqueofferssuperiorpatencyratesoverendtoendanastomosis.30
Theoretically,thisisbecauseofthepropensityofthearterialwalltoretractandconstrict
(asaresultofthemuscularislayer)whencutcircumferentially.Makinganarteriotomy
dividesthecircularmuscularlayeroftheartery,thuseffectivelyholdingopenthe
anastomoticsite.Othershavebelievedthatflowthroughanendtosideanastomosisis
superiortothatthroughanendtoendanastomosis,butseveralstudieshaveshownthat
theflowratesareequivalent.81,91Ibelievethatthegreatertechnicaldifficultywithendto
sideanastomosisthanwithendtoendanastomosismayoutweighthesetheoreticbenefits
whenperformedbyinexperiencedhands.
Thearteriotomyintothedonorvesselisthemostcritical(andirreversible)stepinthe
procedure.Creatingacleanarteriotomyformakinganendtosideanastomosisisperhaps
themostdifficultmaneuverinmicrosurgery.Oneshouldmasterthetechniqueinthe
laboratoryonvesselsofvaryingdiameterandwallthicknessbeforeusingitinclinical
practice.
Thearteriotomymaybedonebyexcisingawedgeofvesselwallwithstraightscissors,
asdescribedbyGodina,30orbegunwithamicroknifeandenlargedcarefullytoan
ellipticalorcirculardefectwithmicroscissors.Specialarteriotomyclampsareavailable,
butthesealsorequirepracticetoachieveconsistentresults.Ifnotappliedproperly,the
arteriotomyclampcancauseirreparabledamagetothevesselwall,whichmustthenbe
repaired(potentiallywithaveinpatchgraft).Anothertechniqueforperforminganarte
riotomyistograspasmallfullthicknessbiteofthevesselwallwithasuture.Thissuture
isthenpulleduptotentthevesselwall,andapairofcurvedmicrosuturesareplaced
underthesuturetocutacleanholeinthevesselatthesiteofthesuture.Arecentstudy
suggeststhatpreparationofadiamondshapedholeintherecipientvesselcreatesa
largercrosssectionalareaforanastomosisthandoesacircularhole.103
Somehavesuggestedthatasimplestraightincisionintothelargervesselissufficientfor
anendtosideanastomosis,5butIprefertocutoutasegment.Thismakesforaneasier
anastomosisbecauseitismuchmoredifficulttograbthebackwall.Likewise,theholein
thelargervesseltendstoholdtheanastomosisopen.Anidealwaytoperforman
arteriotomyiswithasmallvascularpunch.88Thisdeviceisusedbycardiacsurgeonsfor
proximalanastomosesofveingraftstotheaorta.Thesmallestcommercialsizeavailable
isinthe2.4mmrange,butitwillproduceaverycleanarteriotomyforanastomosis,andI

preferthistechniquewithlargervessels.

Fig47.23
Thearteriotomyshouldapproximatelymatchthesizeofthevesseltobeanastomosed.
Theangleoftakeofffromthelargervesselshouldtheoreticallybe90degrees.Inclinical
practice,however,theangleoftakeoffmayneedtobemodifieddependingonthelieof
thevesselsrelativetotheflaporthenecessityofmakinganobliquecutonthesmaller
vessel.Obliquecutsthroughavesselwallmayproduceafragiletipoftissuewiththe
intimaandmediabeingatdifferentlevels,whichisweakbecauseofinterruptionofthe
circularfibersofthevesselwall.Inmostcases,thefrontwallisrepairedfirstandthen
thebackwallissutured(Figure47.23),assumingthattherecipientvesselcanbeflipped.
Usingoneofthetechniquesmentionedforplacementofthelastsutureisespecially
importantincompletingtheanastomosis.Anendtosideanastomosisisprobablymore
easilyperformedwiththebackwallfirsttechniqueifthedonorvesselisdeeplyplaced
andmobilizationoftherecipientvesselisdifficult(Figure47.24).Endtosideanas
tomosesarealsoveryamenabletothecontinuoussuturetechnique.

fig47.24

ContinuousSutureTechnique
Macrovascularandcardiacsurgeonsroutinelyperformvascularanastomoseswitha
continuous(running)sutureofpolypropylene.Thistechniquehasnotfoundwide
applicationinmicrovascularsurgery,butthisisprobablyrelatedtotheorthopaedic
(ratherthangeneralsurgical)backgroundofmanymicrosurgeons.Anumberofstudies
comparinginterruptedversuscontinuoussuturetechniqueinmicrosurgeryhavebeen
performed,withnoclearadvantageofinterruptedovercontinuoussuture
technique.29,34,112,114Theprimaryproblemwiththisapproachinverysmallvesselsisthe
potentialforcreatingapursestringconstrictionatthesiteofanastomosis.Thiscanbe
circumventedbynotrunningasinglesutureallthewayaroundasingleendtoend
anastomosis.Inonereportasocalledcombinedtechniqueofrunningaportionofthe
vesselandinterruptingthelastportionwasused.62Theseauthorsfoundthetimeneeded
foranastomosistobedecreasedwithnoincreaseinthethrombosisrate.Anotherreport
hassuggestedtheuseoffourstaysutures,withacontinuoussuturingtechnique
betweenthesestays.Theseauthorsfoundthatthiscombinedtechniquewassignificantly
fasterthanatotallyinterruptedtechniqueandreportedlessanastomoticleakage,with
100%patencyratesinaseriesofclinicfreetissuetransfers.66Thisapproachisprobablya
verygoodonetospeedupandpreventpursestringingoftheanastomosis.
Theotherproblemencounteredwiththecontinuoussuturetechniqueinmicrosurgeryis
theuseofnylonsuture,whichtendstohavemoreadherencetothevesselwallthanpoly
propylenedoes.Thisresultsindifficultypullingthecontinuoussuturetightafteritis
placed,therebypotentiallyleadingtoalooseandleakyanastomosis.Although
polypropyleneisavailablein90and100sizes,itisdifficulttoworkwithatthissize

andisgenerallyinferiortonylon.
Iroutinelyperformcontinuousanastomosesofmicrovesselswithamodificationofthe
180degreetechniquediscussedpreviously.Inthisapproach,thefirsttwosuturesare
placedbuteachsuturewithneedleisleftinplace.Thesesuturesaretheneachrun
aroundhalfofthecircumferenceofthevessel.Tensionmustbekeptonthesuturebya
followingassistantaftereachthrowisplaced.Ifthisisnotdone,caremustbetakento
tighteneachloopofthesuturebeforetying,orleakswillresult.Thelearningcurveofthis
techniqueisrathersteep;however,withexperienceitcanprovideaveryrapidandsafe
anastomosis.23

SleeveandCuffingTechniques
Inanattempttodecreasethetimenecessaryforanastomosis,severalauthorshave
proposedtheuseofsleeveorendinendtechniques.115Inthisapproach,onevesselis
telescopedorsleevedintoanotherandcanbeheldinplacewithasfewastwo
sutures.Althoughthishasbeenappliedtoeitherendoftheanastomosis,mostauthors
familiarwiththistechniquebelievethatitshouldbeusedonlywhentheupstreamvessel
(fromwhichbloodflows)canbetelescopedintothedownstreamvessel(intowhich
bloodflows).Ifperformedinthisfashion,thesleevetechniquehasequalpatencyrates
withstandardtechniques119andisparticularlyusefulifthereisamarkeddiscrepancyin
sizebetweenthetwovesselsundergoinganastomosis.Iusethistechniqueonoccasion
whenaveingraftisbeingplacedintoalarger,distalartery.Theveingraftistelescoped
intothearteryandheldinplacedistallywithtwosutures.
Avarietyoftechniquesthataddanexternalcuffaroundtheanastomosishavebeen
proposed.74Thiscuffcanbeaslightlylargersegmentofveingraftorsometypeofnon
biologictubing.Theideabehindthisistodecreasethetimeneededforvascularrepairby
usingfewersuturesontheanastomosisitselfandusingthecuffingmaterialtostopleaks.
Thistechniquehasbeenprovedtobeefficaciouswhensuturingverysmallvessels(inthe
0.5mmrange)toavoiddamagetothevesselends.80Inmostclinicalsituations,however,
thisapproachiscumbersome,andthetimesavedbyplacingfewersuturesislostbythe
necessityofharvestingaveingraftandfiddlingwithplacingitaroundtheanastomosis.

NonsutureTechniques
MechanicalDevices
Theideaoftakingthehumanfactoroftechnicalerroroutofvascularanastomosishas
beenaroundforquitesometime.Lapchinskydevelopedacomplexmachineto
anastomoselargervesselsanduseditsuccessfullyforautogenouscaninelimb
replantationsasearlyas1960.59Nakayamaandcolleagueslaterreportedonaringpin
staplingdevicefortherevascularizationoftransplantedintestineforesophageal
replacement.79ThisinstrumentwasfurtherrefinedbyInokuchi,whichpermitteditsuse
invesselsdowntothe2mmrange.48Thisidealayfallowuntilthe1980s,whenOstrup
andBerggrenfurtherrefinedtheringpincouplerintowhatisknownastheUNILINK
system.86ThisdeviceisnowcommerciallyavailableintheUnitedStatesandisusedbya
numberofmicrosurgeons,especiallyforvenousanastomosis.
Theringpintechniqueinvolvespassingeachendofthevesselstobeanastomosed
througharingthathasmatchingsetsofpinsandholes.Thevesselendsaretheneverted
overthecorrespondingpins,andadeviceoperatedbyathumbnutthenpushesthetwo
ringstogether.Thistheoreticallyproducesaperfectanastomosis,withtotaleversionof
theedgesandexactintimatointimacontact.Thisinstrumenthasbeenshowntoprovide
rapidmicrovascularrepairsinexperiencedhands,withpublishedreportsof2to3
minutesperanastomosis.86Ithasbeenusedsuccessfullyformicrovascularsurgeryinthe
handforvascularrepairsandreconstruction.Reportedvascularcomplicationratesare
comparabletothoseofhandsewnanastomosesinexperiencedhands.95,107
Thedownsideofthistechniqueisthatitworkslesswellinarteriesthaninveinsbecause
thethickerarterialwalloftenlendsitselfpoorlytoeversionthroughtherings.Ithas
foundwideapplicationinsomesurgeonshandsforvenousanastomosis,however.End
tosideanastomosiscanbeperformedwiththisdevice,butitlendsitselfpoorlytothis
technique.12Thisdevicehasalsobeenusedforthereplantationoffingers,butIhave
someconcernaboutthepresenceoftheringsinthethinsofttissueofthedigits.
Experimentalworkisbeingdoneondevelopinganabsorbablering,whichmayobviate
thisconcern.90AlthoughuseoftheUNILINKsystemmayhaveapplicationinfreeflap
transferandlargervesselsoftheupperextremity,Ibelievethatthesurgeonshouldbe
wellversedinthestandardtechniquesofmicrovascularanastomosisbeforeattempting
useofthisdevice.
Theuseofstaplesformicroanastomosishasbeenproposed.7,57Theoriginaltechnique

requiredtwostaysuturesandcontinuouseversionofthevesselwall.Successful
applicationofthistechniqueinclinicalcasesoffreeflaptransferhasbeenreported,116
withrapidanastomosistimes(12minutes).Theseauthorshavenoted,however,thatthis
techniquecouldnotbeusedforthickenedarteriesandtherewasahigherrateoflate
stenosis.55Theseearlyvascularstapleswerenonpenetrating,though,andanewertypeof
staplethatpenetratesthevesselwallhasbeenreported.Ithasthesameadvantagesofthe
otherstapleandmayobviateitsproblems.10

Lasers
Themedicalcommunitycontinuestolookforapplicationsforthelaserbeam,and
microsurgeryhasnotescapedthisquest.In1979,anastomosisofvesselswiththe
neodymium:yttriumaluminumgarnetlaserwasfirstperformedexperimentally.50A
numberofcentershaveexperimentedwithlaserrepairofvesselsinthemicrosurgical
range.99,105Thepromiseoflaseranastomosisisthatitavoidstheuseofsuturematerial,
whichmust,ofnecessity,bepresentinthelumenofthevessel(andthuscanpromote
thrombosis).Anunresolvedproblemwithlaseranastomosesisthattheyhaveatendency
forthedevelopmentofpseudoaneurysmswithtime.69Likewise,severalstaysutures
mustbeplacedbeforeweldingthevesselwiththelaser,whichcancelsoutsomeofits
benefits.Onegrouphasreportedtheuseofabiodegradableproteingluefor
anastomosisthatisactivatedbythelaser,67andanotherhasrecentlyreportedtheuseof
photochemicaltissuebondingwithphotoactivedyesthatsealtheanastomosis.85Although
theresultsofthesetechniqueswereacceptable,therehasbeennoclinicalapplicationto
date.Thecostoftheequipmentandthelearningcurveplacelaserassisted
microanastomosisintherealmoftheresearchlaboratoryatpresent,andIdoubtthatthis
techniquewillevereclipsestandardsuturetechniques.Thisismirroredbyadecreasing
numberofreportsintherecentliteratureoflaserassistedanastomosis.

Glue
Theabilitytomakealeakfreeanastomosisisanintriguingone,andthisiswhereinterest
intissueadhesivesformicroanastomoseswasborn.Fibringluehasbeenusedin
microneuralanastomosesforanumberofyears,particularlyinEurope.78Theproblem
withtheuseoffibrininvesselsisthepotentialtoincreasethrombogenicityatthesite,
thusleadingtoocclusionoftheanastomosis.Onestudyfoundthatthepatencyrateofan
anastomosistreatedwithfibringluewasinverselyproportionaltotheconcentrationofthe
thrombininthesealant.68Recentreports,however,haveshownefficacyinusingfibrin
powderorfibringluetosealmicrovascularanastomosesanddecreasethetimeneededfor
anastomosis(bydecreasingthenumbersofsuturesused).11,19,20Theseauthorshave
shownthatthetotalnumberofsuturesplacedcanbereducedsignificantly,which
decreasesthetimenecessaryforanastomosis.Althoughplacingfibrinonaleaky
anastomosismayseemcounterintuitive,onereportofaclinicalseriesshowedsimilarflap
lossratesinasmallseriesinwhichfibringluewascomparedwithstandardsutured

anastomosis.20
Theuseofstandardcyanoacrylateglues(superglue)onvesselshasbeentried,butwith
lessthanoptimalresults.31Thisisprimarilybecauseoftoxicity,whichcausesthinningof
thevesselwallsandthesubsequentformationofaneurysms.Differentformulationsof
thecyanoacrylates(2octylcyanoacrylate)havebeentriedexperimentallyandfoundto
belesstoxicwithreasonablepatencyrates.33Noncyanoacrylateglueshavebeentried
andfoundtobelesstoxicthanthecyanoacrylateswithoutcausingvasculardamageor
thrombosis.26Theuseofglueforanastomosisremainsexperimentalbutmayfindsome
applicationinthefuture,especiallyforprovidingacompletelysealedanastomosis.
Thegoaloftheperfectanastomosis,whichrequireslittleexperience,isperformed
rapidly,andisnonthrombogenic,remainselusive.Withthenotableexceptionofthepin
andringdevice,noneoftheothersuturelesstechniqueshavefoundwideapplicationin
microsurgery.Thesuturedanastomosisremainsthebenchmarkformicrovascular
anastomosisdespitemorethan45yearsofresearchintootherpotentialtechniques.For
thisreason,theapplicationofmicrosurgerytoclinicalsituationsstillrequiresextensive
training,regularpractice,andexperienceforsuccessfuloutcomes.

RevisionoftheFailedAnastomosis
Failureofbloodtoflowacrossananastomosisisusuallycausedbyoneofthreefactors:
(1)technicalerrorswiththeanastomosis,(2)poorflowfromtheproximalvesselbecause
ofundetecteddamagemoreproximallyorvasospasm,or(3)aclotorthrombusatthe
anastomoticsiteorinanareawhereaclampwasapplied.Arecentreviewofalarge
numberoffreetissuetransfersperformedinamajorcenterrevealeda6%rateof
emergencyreexploration.16Mostofthesetransferswereexploredbecauseofvascular
thrombosis,andvenousthrombosiswasfoundtobethreetimesmorecommonthan
arterialthrombosis.Theoverallflapsurvivalratewas98.8%,however,anditwas
interestingtonotethatflapsexperiencingvenousthrombosishadahighersalvagerate
thandidthoseexperiencingarterialthrombosis(71%versus40%.)Flapsthatwere
salvagedwerereexploredmorerapidlythanthosethatfailed,whichwouldcertainly
makesense.
Smallnonoccludingplateletthrombioccurateveryanastomosisandarenecessarytoseal
thesutureline.Ifbloodflowisallowedtocontinueundisturbed,thesethrombiwillnot
usuallyprogresstooccludethelumen.Ithasbeendeterminedexperimentallythatthe
first30minutesisthemostcriticalforthrombusformationwithregardtoocclusionof
thelumen.13Damagetotheendotheliumfromexcessiveclamppressure,poortechnique,
orcontaminationofintraluminalbloodwiththromboplastinsfromthewoundareamay,
however,resultinanoccludingthrombus.Ifbloodflowacrossananastomosismustbe
occludedforanyreason,thesuturelineshouldbebombardedwithheparinizedsolution
immediatelyafterocclusionandbeforeflowisrestored.Systemicheparinwillalso
protecttheanastomosisifreapplicationofclampsisnecessary.

Adequateproximalflowisabsolutelyessentialforsuccessfulanastomosis,and
performingvascularrepairofavesselinwhichthestatusofflowisunknownisarecipe
fordisaster.Forthisreason,Iprefertoperformananastomosiswithoutthetourniquet
inflatedsothattheamountandqualityofinflowcanbeascertained.Justbecausean
arteryispulsatingwithavascularclampinplacedoesnotmeanthatthereisadequate
flowatthesitechosenforanastomosis.Briskbleedingfromtheendofthevesselmustbe
demonstratedbeforeanastomosis.Ifbleedingisnotadequate,asmallclotmaybepresent
orthevesselmaybeinspasm.Intheworstcase,thevesselwillbedamagedandneedto
beresectedfartherbackbeforeanastomosis.

Determiningthepatencyofananastomosiscanpresentproblemsevenforexperienced
microsurgeons.Partialthrombiatthesiteofrepairmaycauseintermittentflow,witha
normalpatencytestresultdistally.Ifthepatencytestrevealsslowfillingofthedistal
vessel,whetherarterialorvenous,theanastomosisshouldbetakendownandexamined.
Althoughtheideaofremovingafewsuturestoinspecttheintimaandremoveclotseems
appealing,Ibelievestronglythatanymicroanastomosisthatisquestionableshouldbe
revisedcompletely.Inspectionoftheresectedsiteofanastomosisshouldalwaysbe
performed,bothforpurposesofdeterminingthecauseofthrombosisandforavoiding
similarproblemsinthefuture.
Oneshouldattempttodiscernthecauseoffailureandproceedaccordingly.Ifthereis
sufficientvessellength,reanastomosiscanbeperformed;ifnot,aveingraftisinserted.
Poorproximalflowthatdoesnotrespondtolocalvasodilatorsandwarmingmayrequire
proximalexplorationofthevessel,dilationalongaproximallengthofvesselsufficientto
relievevasospasm,treatmentwithlocalorintraarterialvasodilators,oranycombination
ofthesemeasures.
Insomecases,aveingraftfromanadequatedonorvesselmoreproximallymaybe
required.

VeinGrafts
Oneofthemostcriticalessentialsofmicrovascularsurgeryisthattherenotbeexcessive
tensionontheanastomosis.Experimentalstudieshaveshownahighincidenceof
aneurysmformationandthrombosisinvesselssuturedundertension.96Bothveinsand
arterieshavebeenusedforinterpositionalgraftsinmicrosurgery,butvenousgraftsare
themostreadilyavailableandmayhavethehighestpatencyrate.101Therehasalways
beensomeconcernthattwoanastomoses(aswhenaveingraftisused)maybeinherently
morepronetothrombosisthanasingleanastomosis(directrepair).Ifaprimaryrepairis

doneundertension,however,thereisnoquestionthataveingraftissuperior.Reportsof
clinicalseriesshowthatlongveingraftsdonotincreasethelikelihoodofflaploss,other
thanfromthestandpointofthedifficultyofreconstructionintheseinstances.51Likewise,
mostauthorsbelievethattheadvantagesofusingaveingraftinadifficultsituationfar
outweighthepotentialdisadvantages.
Althoughdorsalhandveinsarecommonlyusedindigitalreplantationand
revascularization,theyarelargerthanthedigitalvessels.Thesmallvolarsubcutaneous
veinsjustproximaltothewristarelongandstraightwithmatchingdiameterandhave
fewmajorsidebranches.Thedorsalhandveinsandthecephalicveinnearthewristare
appropriatelysizedforpalmarandforearmvessels,asisthelowersaphenousveinabove
theankleforfreeflappedicles.Thesaphenousisverydifferentfromupperextremity
veins,however,andthisshouldbetakenintoaccountifitisselected.Ithasaverythick
muscularwallandcanpresentproblemswithspasm.Itisnotanappropriategraftinmost
instancesdistaltothewrist.Itshouldbenotedthatveingraftsthatarelargerthanthe
diameterofthearteryneedinggraftingdonotusuallypresentproblems,butexperimental
workhasshownthatasignificantlysmallerveingraft(50%diameter)leadstoahigher
thrombosisrates.39
Allveingraftsshouldbemarkedandreversedwhenusedforarterialreconstruction
becauseeventhesmallestdigitalveinscontainvalves.Mostauthorsrecommend
completionofbothanastomosesbeforeremovaloftheclampstopreventthrombosisat
thesiteofthefirstrepair.Theanastomosesshouldbebrisklyirrigatedwithheparinized
solutionbeforeremovaloftheclamps.Veingraftsalwaysseemtoelongateafter
reperfusion,anddeterminationofthelengthofveingraftneededtobridgeadefect
requiresconsiderableexperience.Ifthegraftistooshort,tensionwillbepresentatthe
anastomoses;iftoolong,retractionofthearterialendswithconcomitantnarrowingor
kinkingoftheelongatedgraftmayoccur.Whenpossible(i.e.,inelectiveprocedures),the
defecttobegraftedshouldbemeasuredbeforeexcisionandtheveingraftmeasuredand
markedbeforeharvesting.Measuringtheveingraftinsitu(tomatchthearterialdefect)
beforeitisdividedisprobablythebestwaytoavoidmakingittooshortortoolong.
Anothertechniqueistocompletetheproximalanastomosisfirstandallowbloodtofill
thegraft.Thistechniquewillusuallymaketheveingraftassumeitsnaturallength,andit
canbetrimmedappropriatelyoncefilledunderarterialpressure.Althoughthismay
theoreticallyincreasethechanceforthrombosisoftheproximalrepair,suchthrombosis
rarelyoccursinclinicalpractice.Experimentally,thegraftcanbeupto35%longerthan
thereplacedsegmentwithoutkinking.101Anotheroptionistofilltheveinwith
heparinizedsalineandclampitatbothendsafterharvesting.Theveinisthen
anastomosedjustbeyondtheclampswhileitisstilldistendedwithsaline.Thistechnique
avoidskinkingandmaypreventlaterspasmasaresultofhydrostaticdilation.
Forreasonsofpotentialtwistingofthegraftandappropriatetrimming,Ialwaysperform
theproximalanastomosisfirstandthenallowtheveingrafttoperfusewitharterialblood.
Ifthedistalendiskeptclampedforashortperiod,thegraftwillunwindandextendto

itsfulllengthoncedistendedwitharterialpressure.Oncetheappropriatelieandlengthof
thegrafthavebeendetermined,amicrovascularclampcanbereplacedupstreamfromthe
proximalanastomosis.Theveingraftisthenflushedwithheparinizedsalineandthe
distalanastomosisperformed.Ihavefrequentlyusedthistechniqueandnotfound
thrombosisoftheproximalanastomosistobearecurrentproblemdespitefearstothe
contrary.

ProstheticGrafts
Althoughadequateprostheticvesselsexistforthemacrovascularsurgeon,theuseof
vascularprosthesessmallerthanadiameterofapproximately6mmremainsproblematic.
Someserieshavereportedhighpatencyrateswithsmallprostheses,42butingeneral,
longterm(3weeks)patencyratesarelowerthanwithautogenousveingrafts.Atthe
microvascularlevel,allprosthesestrieduptothistimehavehadveryhighthrombotic
ratesatthesiteofanastomosiswithstandardtechniques.Oneoftheprimaryproblems
presentedisintheanastomoticsite.Thisproblemisamelioratedsomewhatbyusinga
sleevetechnique(seepreviousdiscussion)betweentheprosthesisandthenativevessel,
butlongtermpatencyisrelativelypoor.Althoughtheseproblemswillprobablybe
workedoutinthefuture,atpresentthereisnosuitableprostheticvesselreplacementfor
microsurgicaluse.

VenousDrainage
Inadequatevenousdrainageisacommonproblemindigitalreplantationandis
occasionallyseeninfreetissuetransferaswell.Venousdrainageofthedigitshasbeen
studiedingreatdetail,andanunderstandingofvenousanatomymayallowlocationof
additionalveinsforanastomosis.77Transferofveinsdissectedfromadjacentareasor
digitsmaybehelpful.Insituationsinwhichadequatevenousdrainagecannotbe
establishedorcongestionappearslate,severalmeansofaugmentationofvenousdrainage
havebeendescribed.
ThemedicinalleechHirudomedicinalishasbecomewidelyusedtocompensateforpoor
venousoutflow,particularlyincasesofreplantation.56Leechesarequiteeffectivein

removingvenousbloodbyfeedingandbytheoozingthatoccurslaterfromthepowerful
anticoagulant(hirudin)thattheyinjectlocally.Medicalgradeleechesareavailable
within24hoursfromNewYorkforuseintheUnitedStatesorfromGreatBritainforuse
inEurope.Themainmorbiditywithleechesisthepresenceofthesaprophyticorganism
Aeromonashydrophilaintheirgut,whichcancauseinfection.Thishasprimarilybeen
seeninpatientswithnecrotictissueatthesiteofleechapplication.64Prophylaxiswitha
thirdgenerationcephalosporinisappropriatetodecreasetheriskforinfection.Leeches
mayhavesomeplaceinsalvagingareplanteddigitbutarenotadequateintheeventofa
failingflap.Toomuchbloodispresentinaflapforanynumberofleechestodrainthe
excessinapatientwithapatentarterialanastomosis.Leechesshouldnotbesubstituted
foranappropriatereturntotheoperatingroomtorevisethevenousanastomosisifitis
occluded.
Survivalofreplanteddigitswithoutvenousanastomosishasbeenreportedwiththeuseof
heparinanticoagulationandopendrainageofthepart.98Bloodlosswiththistechnique
canbesubstantial,however,andtherisksassociatedwithtransfusionmustbeweighed
againstthefunctionalneedfortheamputatedpart.Venousdrainagecanalsobe
augmentedbyremovalofthenailandheparinization.Bloodlossislesswiththis
technique,andsurvivalrateshigherthan70%havebeenreported.Others,including
myself,havebeenunabletoachieveeventhereasonablesuccessratesreportedwiththese
techniques;myfailurerateapproaches100%.
Despitethemethodused,ifthepartsurvives,venouscongestionusuallydisappears
betweenthefifthandseventhdays.Theexactmechanismisunknown,butpresumably
sometypeofcollateralvascularchannelisreestablished.Thetimerequiredfor
reestablishmentmayvarywiththetypeoftissue(skin,subcutaneous,muscle),andlate
lossofthepedicleinfreetissuetransfershasbeenreported.

MaintainingFlow
Oncetheanastomosesarecompleted,whatadditionalstepscanbetakentoimproveor
maintainbloodflow?Bothpharmacologicandnonpharmacologicmethodshavebeen
suggested,butnonewillsubstituteforatechnicallyadequateanastomosisofnormal
vesselendswithouttension.Measuresusedempiricallyoftenhavesomebasis,andothers
havebeenstudiedclinicallyorinthelaboratory.Thefirstopportunitytoprotectthe
anastomosisisduringtheprocedure.Meticuloushemostasiswillpreventhematoma
formation.Fasciotomyafteralongischemicintervalinlimbreplantationwillprevent
constrictionsecondarytopostoperativeswelling.Warmingtheamputatedpartorflapwill
reducevasospasmandincreaseflow.
Thewoundisclosedinsuchawaythatthevesselsarenotkinkedorcompressedand
laterswellingorhematomadoesnotcompromisethelumen.Veins,beinglowpressure
systems,aremorepronetotheseproblems,andmanyclinicalfailureshavebeen
attributedtovenouscompromise.Thewoundmaybeleftpartiallyopen,aswiththe

midlateralincisionusedforreplantation,orlooselyclosedoverdrainsifadequateskinis
available.Ifnot,localflaps,primaryskingrafting,orotherbiologicdressingsmay
providecoveragewithoutconstriction.Itisalwaysbettertoplaceasmallnonmeshed
skingraftoverthevesselsthantooccludethemwithskinclosure.Iagreestronglywith
Schekerandassociates,whoadvocatemonitoringtherevascularizedpartduringclosure
toavoidcompressionofthepedicle.100Drainsshouldbesoftandpliable(Penroseor
silicone)andshouldnotbeplaceddirectlyagainstthevesselssothattheirsuctionor
removaldoesnotcausevasospasm,thrombosis,ornecrosisofthevesselwall(allof
whichIhaveseen).Theymaybesuturedinplacewith60plainsuturetoprevent
migrationbutstillallowlaterremoval.
Thedressinghasseveralfunctions:itprotectsandimmobilizestheextremityandshould
providegentlecompressiontocontroledema.Softpaddingisplacedbetweenthedigits
afterwoundcoveragewithnoncircumferentialdressings.Dressingremovalmaycause
painandsecondaryvasospasm.Afterreplantationormicrovasculartissuetransfer,I
prefertonotchangeormanipulatethedressingforatleast5to7days
postoperatively,ifpossible.Therefore,incasesinwhichdressingchangeisrequired
earlyinthepostoperativeperiodbecauseofexcessivebleeding(usuallyseenwith
heparinization)orthepossibilityofinfectionorforsecondaryskingrafting,Iremovethe
dressinginawarmedoperatingsuitewiththepatientunderlongactingaxillaryblockor
generalanesthesia.

Becausevenouscongestionseemsmorecommonthanproblemswithadequatearterial
inflow,elevationisusuallyprescribed.Lesselevationorevenadependentpositionhelps
arterialinflowbutincreasestheriskforedemaandvenouscongestion.
Mostflapsthatarelosthavetheirinitialprobleminthefirstseveralhoursaftersurgery.It
isobviousthatproblemsintheearlypostoperativeperiod(first12hours)areprimarily
duetotechnicaldifficultiesattheanastomosis.Thrombosisofanintactanastomosiscan
alsooccurduringthisperiodasaresultofcompressionfromahematoma.Afterthis
initialstage,fewflapsarelostuntiltheperiodof8daysto2weeks.Atthispoint,the
anastomoticthrombosesthatoccuraregenerallyduetoanabscessaroundthepedicle.
Experimentally,75%ofanastomosesperformedinthepresenceofastaphylococcal
infectionthrombose.65Evenadistantinfectioncanleadtoanastomoticthrombosis,and
studieshavedocumentedamicrovascularthrombosisrateofapproximately20%inthe
presenceofdistantinfection.72

PostoperativeMeasures
Oncethedressingisapplied,mostmeasuresaredirectedtowardpreventionof

vasospasm.Ofthefactorsinfluencingbloodflowthrougharevascularizedpart,several
areundersympatheticcontrol(Figure47.25).Thefollowingmeasuresappeartobe
widelyrecommendedbymostmicrovascularsurgeons.
1. Bedrestorlimitedmovingofthepatientfor3to5days
2. Roomwarmedabove78F(replantsandtoetransfersonly)
3. Privateroomandlimitingofvisitorsandtelephonecallstodecrease
emotionalstress
4. Adequateanalgesia
5. Prohibitionofsmoking,caffeine,andchocolatebecausetheymaycause
vasoconstriction
Vascularthrombosis,ifitoccurs,ismostlikelyinthefirst12hoursaftercompletionof
theanastomosis,asnotedpreviously.Forthisreason,Iadvocatecloseexaminationofthe
flapduringtheinitial10to12hourpostoperativeperiodbyanexperiencedobserver,
usuallyamemberofthesurgicalteam.Afterthispoint,hourlychecksbythenursingstaff
(withroutinephysicianrounds)areprobablyadequate.
Fluidadministrationlowersbloodviscosityandmaintainscardiacoutputtoprovide
adequatearterialinflow.Vasopressoragentsarecontraindicated.Oxygenadministration,
duringperiodsofpostanesthesiarespiratorydepression,andtransfusiontomaintain
adequatehemoglobinlevelswillimproveoxygenationoftherevascularizedpart.
Althoughpracticedbymanymicrosurgeons,subjectingthepatient,staff,andsurgeontoa
roomwithsemitropicaltemperatureisusuallycruelandunusualpunishment.Flaps
placedonthebodysurfacearemuchmoresensitivetothepatientscoretemperaturethan
toambienttemperature.Replanteddigitsandtransferredtoesmaybeverysensitive,
however,toacutechangesintemperature.Althoughitiswisetoplacepatientsinthe
immediatepostoperativeperiodinawarmroomafterreplantationortoetransfer,the
temperaturecanprobablybenormalizedforcomfortafterthepatientisawakeand
stable.
Inmicrovascularproceduresinvolvingtheupperextremity,Ifrequentlyusean
indwellingbrachialsheathcatheterplacedbytheanesthesiologist.Thiscathetercanbe
usedforoperativeanesthesiaandmaintainedfor3to5dayspostoperatively.Thecatheter
isattachedtoabupivacaine(Marcaine)pumpthatmaintainsacontinuousaxillaryblock
inthepostoperativeperiod.Iusethisprimarilyforitssympathectomyeffect,butithas
theaddedbenefitofsignificantlyreducingpainintheoperatedlimbinthepostoperative
period.Onereporthasnotedadecreaseinflowtotherevascularizedtissueiftheblockis
placedaftervascularanastomosis,whichwasbelievedtobetheresultofavascularsteal
phenomenon.113Forthisreason,theblockorcathetershouldbeplacedbeforeperforming
theanastomosis(atthebeginningoftheprocedure).
Althoughendothelialregenerationbeginsimmediately,experimentalstudieshaveshown
thataslongas21daysmayberequiredforcompleteregenerationatthesiteofrepair.106
Exposedsuturesmaynotbetotallycoveredwithendotheliumforupto5weeks,and

thereforeIbelievethatsomecareshouldbeexercisedforupto3weeks.Iaskthatthe
patientabstainfromcaffeineandsmokingforthisperiodtoavoidproblemswith
vasospasm.

FailureofReperfusion
CrushandAvulsionInjuries
Failureofbloodflowthroughananastomosismaybeimmediateordelayed.Ifproximal
bloodflowwasverified,therepairwastechnicallywellperformed,andvasospasmhas
beentreated,briskflowusuallyoccurs.Ifnot,theproblemisprobablytobefoundinthe
revascularizedpart.Immediatefailureofflowmaybeduetounrecognizedvesseldamage
moredistally,whichshouldbeidentifiedandcorrectedwithaveingraft.Itisalso
importanttomakesurethattheanastomosiswasnotmadedistallytoaveininsteadofan
artery.
Inreplantation,injurytotheamputatedpartmaybeofsuchseverityandextentthat,
perhaps,disseminatedcoagulationoccurredinthedistalvesselsandcapillarynetwork.
Softtissuedamageoccurringinanamputatedpartafteritisdetachedmaynotbeobvious
untilitisrevascularized.Crushandavulsioninjuriesmayproducesufficientintimal

damagetomassivelyactivatethecascademechanismbyactivationoffactorXII.Ifthis
occurs,significantflowdoesnotoccurintotherevascularizedpartafter
revascularization.Milkingtheamputatedpartbeforerevascularizationorperfusionwith
fibrinolyticagents,freeradicalscavengers,oroxygenatedbloodsubstitutesmighthelp
(theoretically),butinourexperiencethesedigitsarenotgenerallysalvageable.

ReperfusionInjury(NoReflowPhenomenon)
Occasionallyafterawellperformedanastomosis,arterialinflowcanbedemonstratedby
initialbleedingfromtherevascularizedpartandpatencytestsmayindicatepatencybut
venousreturnissluggishorabsent.Gradualcessationofflowthenoccurs,thedistal
bleedingceases,andthearterialanastomosisfails.Thisistermedthenoreflow
phenomenon,whichwasfirstdescribedafterrevascularizationinthecerebralcirculation
andlaterinexperimentalflapsbyMayandcolleagues.70Experimentalstudieshave
showna50%incidenceoffailurecausedbynoreflowafter4hoursofwarmischemia
timeinrathindlimbs;ongoingarterialobstruction,arteriovenousshunting,and
alterationsintheclottingmechanismweresuggestedaspossiblefactors.118Othermore
likelypossibilitiesinclude(1)edemaandswellingofthevascularendotheliumand
parenchymalcellswithresultantnarrowingofthecapillarylumen,(2)disseminated
intravascularthrombosis,and(3)lossofphysiologicintegrityofthevenuleorcapillary
wall.
Whetherpriorperfusionwithvarioussolutionssignificantlyaffectstherateofultimate
survivalinexperimentalsituationsisasyetundetermined.However,perfusionwith
oxygenatedfluorocarbon,Collinssolution,orhemoglobinperfusionsolution,combined
withhypothermia,hasbeenshownexperimentallytomarkedlylengthentheallowable
ischemicinterval.PerfusionwithheparinizedsalineorlactatedRingerssolution,orwith
both,hasbeenshowntobedetrimentaltomostischemictissues,however.Raisingaflap
sometimebeforetheactualtransfer(flapdelay)increasesthetimethatitmayremain
devascularizedwithoutdemonstratingthenoreflowphenomenon.
Alphareceptorhypersensitivitytocirculatingcatecholaminesmayplayarole,andthe
delayphenomenonmaysomedaybeexplainedbyabetterunderstandingofnoreflow
problems.
Otherresearchhasimplicatedreperfusioninjuryandtheproductionoffreeradicalsasthe
causeofthenoreflowphenomenon.Duringprolongedischemia,adenosinetriphosphate
isbrokendowntohypoxanthine,andxanthineoxidaseisformedbytheactionofa
proteaseinresponsetothelowoxygentensionproducedbyischemia.Whenreperfusion
occurs,thepresenceofmolecularoxygenallowstheconversionofhypoxanthineto
xanthineandsuperoxideradicals(oxygenfreeradicals).Theoxygenfreeradicalmay
reactfurtherwithwatertoproducehydrogenperoxide,andhydrogenperoxidemaythen

alsoreactwithotheroxygenradicalstoformhighlyreactivehydroxylradicals(OH ).
Duringnormalmetabolism,superoxidedismutase(SOD)ispresentinsufficient

quantitiestoscavengethesefreeradicalsandpreventdamage,butafterlongperiodsof
ischemiathissystemisoverloadedbyexcessfreeradicals.
Tissuedamagefromreperfusionmaybedecreasedbyblockingtheconversionof
hypoxanthinetoxanthineorbyprovidingexcessSODtoscavengetheoxygenfree
radicals.Allopurinolblockstheformerreactionandhasbeenshownexperimentallyto
exertaprotectiveeffect.47SODandotherfreeradicalscavengersarestillinvestigational
drugsandarenotavailableforclinicaluse.Somecenters,however,routinelygive
allopurinolafterreplantationinanattempttoprovidesomeprotection.Ihavenotadopted
thistreatmentbecauseofthepotentialsideeffectsofthisdrug.
Unfortunately,atthepresenttimethereisnosatisfactorytreatmentoffailureof
reperfusion,andthesedigitsorflapsareusuallylost.Treatmentoftherevascularizedpart
withfibrinolyticagents(urokinase,streptokinase)hasbeensuggestedinthesesituations.
Improvementofflowinischemicflapsandinhandischemiasecondarytodistalarterial
occlusionhasbeendemonstratedwiththrombolytics.Humanrecombinanttissue
plasminogenactivatorhasbeenusedeffectivelyforpartialflapsalvagemorerecently.
However,anexperimentalstudydesignedtotesttheeffectofintravascularfibrinolysis
onsmallvesselthrombosisshowednoeffectinvesselswithaninternaldiameterof0.8to
1.5mm.22

MonitoringTechniques
Lossoftherevascularizedtissuemayoccurinthepostoperativeperiodasaresultofloss
ofarterialinfloworvenousdrainage,orboth.Afterreplantation,thereisafailurerateof
15%to25%.Infreetissuetransfer,toachievea90%to95%successrate,upto20%of
patientswillhavetobereoperatedonforrevisionoftheanastomosis.63Inviewofthe
investmentoftime,surgicalrisk,andfinancialconsiderationswithmicrosurgical
procedures,anobjectivemeansofmonitoringishighlydesirable.

Theidealmonitoringsystemshould

Besafe,reliable,inexpensive,andnoninvasive
Providecontinuousmonitoringandrapidindicationofimpairedperfusion
Distinguishbetweenarterialandvenousobstruction
Beabletomonitoralltypesoftissues
Beeasilyinterpretedbynursingpersonnel

Onemustrememberthatthemostreliablemonitoroftheadequacyofperfusionisan
experiencedobserver.Nomachinetodatehasbeenfoundtobefoolproof,andalldata
fromsuchinstrumentsrequireatleastsomeinterpretationbytheobserver.Thesurgeon

shouldbethoroughlyfamiliarwithwhatevermonitoringdeviceischosen,however,and
thepersonnelshouldhaveanunderstandingofhowitworksanditsfoibles.Biomedical
technologyhasproducedseveralinstrumentsformonitoringthevascularityoftissue,but
unfortunatelynooneinstrumentisoptimalforallclinicalsituations.Endorgansystems
suchasreplanteddigitscanbeadequatelymonitoredwithtemperatureprobes,andthis
techniqueiswidelyused.Theequipmentisrelativelyinexpensive,theminimum
temperatureassociatedwithviabilityisgenerallyacceptedas30C,andinterpretationby
nursingpersonnelisstraightforward.Monitoringfreetissuetransferssurroundedbyor
buriedinotherwellvascularizedtissuecannotbedoneadequatelybytemperature
measurement.Thetransferwillassumethetemperatureofitssurroundingsandthusmay
remainwarmevenifnonviable.Moresophisticatedmonitorsarethereforerequired.
Transcutaneousoxygenmeasurement,laserDopplerflowmetry,pHmonitoring,and
photoplethysmographyhaveallbeenusedforclinicalmonitoringbyvariouscenters,and
thechoiceofmonitoringtechniquedependsonthesurgeon.Therecentdevelopmentofa
smallimplantableDopplerprobethatcanbeplacedoneitherthearteryorveinatapoint
beyondtheanastomosishasprovedtobeanexcellentmonitoringsystemforfreetissue
transfers(seeFigure47.25).83,89Thisprobehasafewproblemsassociatedwithitsusebut
willrapidlyrecognizeanylossofflow.Inowusethistypeofmonitoringforallfree
tissuetransfers.

Hypercoagulability
Patientswithabnormalitiesoftheclottingmechanismcanpresentformidableproblems
forthereconstructivemicrosurgeon.Ifapatienthasproblemswithrecurrentthrombosis
aftermicrovascularanastomosis,aworkupforoneofthehereditarythrombotic
disorders,includingdeficienciesofantithrombin,proteinC,andproteinS,should
certainlybedone.Themicrosurgeonshouldalsobeawarethatcertaindiseasestatescarry
anincreasedriskforhypercoagulability,amongwhicharecancerandpremature
atherosclerosis.OnestudyfoundabnormalproteinClevelsin70%ofagroupofcancer
patientsundergoingfreeflapreconstruction,butthishadlittleeffectonflaploss.8Fourof
sevencancerpatientsinanotherstudywerefoundtohavetheparametersof
hypercoagulabilityonpreoperativelaboratoryexamination,butwithappropriate
antithromboticmanagementtherewerenoflaplosses.84Anothergroupofpatients
frequentlyseenwithhypercoagulablestates(whichisoftenoverlooked)arethosewith
type2diabetes.Thesepatientsoftenhaveelevatedlevelsoflipoprotein(a),whichis
associatedwithahypercoagulablestate.Somemicrosurgeonsroutinelyscreendiabetics
forelevatedlipoprotein(a)levelsbeforeattemptingmicrovascularreconstruction.
Heparinorlongtermoralanticoagulation(orboth)willamelioratemostthromboticepi
sodesinthesepatients.Mypersonalmicrovascularexperiencewithseveralpatientsfound
tohavehypercoagulablestates(afterfailedmicrovascularprocedures)hasbeendismal,
whichhasbeentheanecdotalexperienceofseveralcolleaguesaswell.Individualswith
recognizedhypercoagulabilityshouldprobablynotbeconsideredcandidatesforelective
microvascularreconstructivesurgerybecausetheymaypresentinsurmountableproblems
withvascularthrombosis.

ParametersofSuccess
Withexperience,microvascularsurgeryshouldprovidereliablerestorationofflowto
severedpartsandfreetissuetransfers.Theresultsofthesurgeryshouldnolongerhinge
solelyontheabilitytokeepthetissuealive.Unfortunately,evenafternearly45yearsof
experiencewithmicrosurgery,successrateshavenotreached100%,noraretheylikely
toaslongasthereisahumanelementinvolved(onthepartofboththesurgeonandthe
patient).Fewstudieshavelookedatalargenumberofpatientsprospectivelyintermsof
whatfactorsportendsuccessorfailureinmicrovascularsurgery.Recently,however,
Khouriandcoworkersundertookaprospectivestudyinvolving23experienced
reconstructivemicrosurgeonsinaworldwidesurveyofthissort.52Manyoftheirfindings
arenotsurprising,butafewshouldbenoted.
Atotalof496microvascularfreeflaptransferswereincludedinthestudy,withaflap
failurerateof4%.Tenpercentoftheflapsrequiredreexplorationforpostoperative
thrombosis,andtherewasan8%intraoperativethrombosisrate(exclusiveofthe
postoperativethromboses).Veryfewfactorshadastatisticallysignificanteffecton
successorfailureoftheprocedure.Theonlytechnicalfactorwithapositiveeffect
(increasedsuccessrate)wastheanastomosisofmorethanoneveinperflap.Theonly
factorwithanegativeeffect(decreasedsuccessrate)wastheuseofaninterposition
veingraft.Whetherthismeansthattwoanastomosesareriskierthanoneisnotclear;this
relationshipmayinfactbeduetotheincreasedcomplexityofproceduresrequiringvein
grafts(withresultantincreaseinflaploss).Eachofthecentersusedavarietyofdifferent
protocolsintermsofpharmacologictreatmentofthesepatients,yetnoneofthese
protocolsshowedastatisticallybetterflapsurvivalrate.Itisinterestingtonotethatthe
routineuseofintraoperativeheparin(eitherasabolusoradrip)wasassociatedwithan
increaseinflapfailure.
Thesedataseemtoconfirmtwopoints:(1)evenwithexperience,microvascular
anastomosisisnotsuccessful100%ofthetime,and(2)goodsurgeryismoreimportant
thanpharmacologyintermsofasuccessfuloutcome.

OrganizingaMicrosurgicalService
Replantationandfreetissuetransfercanbetediousanddemandingproceduresandfor
manyreasonsarebestperformedwithateamconcept.Astheteammemberswork
togetherandlearntheirrespectivetasks,lesstimewillbewastedandfrustrationwillbe
minimized.Readerscontemplatingsuchanundertakingarereferredtoguidelinesfor
organizingamicrosurgicalteam.76

PharmacologyofSelectedDrugs
Thetimingandrouteofadministrationofpharmacologicagentsareimportanttoachieve
maximumbenefit.Thestressofanesthesiaandsurgerycausesepinephrinetobereleased
intothecirculation,thusincreasingthepossibilityofthrombosis.Prophylactic
adjunctivedrugtreatmentshouldthereforebeconsidered.Althoughre
endothelializationbeginsimmediately,someformofanticoagulanttherapyshouldbe
continuedforatleast3to5daysuntiltheendotheliumregeneratesandcoversthe
anastomoticsite.Diurnalvariationsincoagulabilityalsooccurandmayaffectthe
outcomeofmicrovascularprocedures.Thereadershouldbeawarethatthe
recommendationsthatfollowregardingindividualdrugsareinmostcasesbasedonfirm
theoreticconsiderationsbutthatsupportingexperimentaldataorcontrolledclinicaltrials
areinmostcaseslacking.

Anticoagulants
Heparin
Heparinisacomplexsubstancewithmultipleactionsinvivo.Mostimportanttothe
microvascularsurgeonisthepreferentialbindingtovascularendothelialcellsthat
replacesthenormalnegativechargelostinareasofendothelialdamage.Thishigh
concentrationintheareaofdamagealsoinhibitsplateletaggregation,decreases
fibrinogenclotting,andactivateslocalantithrombinIII.Systemicheparinalsohastwo
directeffectsonblooditself:activationofserumantithrombinIIIandloweringofblood
viscosity.Whensharplydividedvesselsarerepaired,thepatencyratewhensystemic
heparinisusedasanadjunctisprobablynogreaterthanthatinuntreatedcontrols.
However,anotherlaboratorystudydesignedtotesttheefficacyofsystemicheparinafter
crushandavulsioninjuriesshoweddramaticimprovementinthepatencyrateafterrepair
oftraumatizedvessels.21Inaddition,inaretrospectivestudyofreplantationfailures,20%
occurredwithin4hoursofdiscontinuingsystemicheparin.41Thissamestudysuggested
thatfullheparinizingdoseswererequiredandthatlowdoseregimenswereineffectual.
However,lowdoseregimensandheparinanalogswithlesseffectonoverallclottingare
attractivefromthestandpointofbleedingcomplications.Studiesofacontinuouslow
doseinfusionofheparininthepostoperativeperiodhavedemonstratedimprovedflap
survivalrateswithnoincreaseinbleedingcomplications.Fullheparinizingdoses
generallyrequiretransfusionandrepeateddressingchanges.
Althoughheparinizationisprobablynotneededforthereplantationofsharpamputations
oruncomplicatedfreetissuetransfer,itshouldbeconsideredstronglyinproblemcases
suchasavulsionorcrushinjury,whichwouldbeexpectedtoexposemultipleareasof
endothelialinjury.Patientsdemonstratingatendencytohypercoagulabilityand
thrombosisrequiringanastomoticrevisionshouldalsobeprotected.Inpatientswhoare
hypercoagulable,afullheparinizingdoseof40U/kgofbodyweightshouldbegiven
beforecompletionoftheanastomosisandreleaseoftheclamps.Iftherehassimplybeen

thrombosisofananastomosisintraoperatively,asmallerdose(inthe1500to2000unit
range)shouldbegiventoavoidbleedingcomplications.Heparinisalsoimportantasa
localanticoagulantinirrigatingsolutions.Guidelinesfortheuseofheparinin
microsurgeryhavebeenoutlinedintherecentliterature.61,87Complicationsofheparin
includebleedingandheparininducedthrombocytopeniaandthrombosis(HITT).

Hirudin
Hirudinisanisopolypeptideproducednaturallyinsmallamountsbythemedicinalleech
H.medicinalis.Itsexistenceandeffectshavebeenappreciatedformanyyears,especially
inrelationtotheuseofleechesforvenouscongestioninmicrosurgery(seeearlier).
Hirudinisadirectinhibitorofthrombin.Itisnotinactivatedbyplateletfactor4andmay
bemoreeffectiveinthepresenceofplateletrichthrombus.32Itisavailableasa
recombinantproductintheformofdesirudinandlepirudin.Ithasfoundapplication
primarilyinthemanagementofpatientswithHITTwhorequireanticoagulationbutare
severelyallergictoheparin.Althoughithasnotbeenreportedintheliterature,Ihave
usedlepirudininacaseoffreetissuetransferinapatientwhosufferedfromHITT.After
thrombosisofthearterialanastomosiswithtworevisions,lepirudinwasused
systemicallyandasanirrigantsolutioninlieuofheparin.Nofurtherproblemswere
encounteredandtheflapproceededtototalsurvival.Furtherstudyofthisagentandits
useinmicrosurgerymayproveitsusefulness.

AcetylsalicylicAcid(Aspirin)
Aspiriniswidelyusedaftermicrovascularproceduresbecauseofitsantiplateleteffect.
Administrationofasingledoseaslowas3mg/kgwillinactivatecirculatingplateletsby
acetylatingtheenzymecyclooxygenasepresentintheplateletwall.Arachidonicacid
cannotbemetabolizedtoprostaglandinsG2andH2,andthromboxaneA2cannotbe
formed.ThromboxaneA2isnecessaryforthereleasephenomenonthatleadstoplatelet
aggregation.However,aspirinalsoblocksthesynthesisofprostaglandinI2(PGI2)inthe
vesselwall.PGI2hasseveralbeneficialeffects,includinglocalvasodilationand
blockageofplateletaggregation.Fortunately,vascularendotheliumhastheabilityto
resynthesizecyclooxygenase(plateletscannot).Moreover,theeffectofaspirinisdose
related.Theaveragedoserequiredtoinhibit50%ofplateletaggregationis3.2mg/kg,
but4.9mg/kgisneededtoinhibitPGI2productionbythevesselwall.18Becauseofthis
differentialeffect,asmalldoseofaspirinistheoreticallyindicated.Therecommended
doseis3mg/kg(2.5to3.5grains)daily.Asecondaryplateletreleasephenomenon
(whichisnotblockedbyaspirin)maybestimulatedbythrombinandhighcollagen
concentrationsandmayexplainthelackofbleedingproblemsnotedwhenaspirinis
givenaftertrauma.
Dipyridamoleisanaspirinanalogthatalsohasantiprostaglandineffects.Itsmetabolism
hasnotbeenaswellstudied,anditprobablydoesnotofferanysignificantadvantage
overaspirin,exceptpossiblyaconcomitantvasodilatoryeffect.Itappearstorarelybe
usedbymicrosurgeonsatthistime.

Dextran
Themechanismofactionofdextranisnotwellunderstood,butitappearstohaveboth
antiplateletandheparinlikeeffects.Althoughithasbeenwidelyusedinmicrosurgery
becauseofitspresumedlowerincidenceofsideeffects,goodstatisticalevidenceto
supportitsclinicaluseislacking.Pharmacologically,dextranisclassifiedasaplasma
expander,anditisindicatedfortheprophylaxisofdeepvenousthrombosisand
pulmonaryembolisminpatientsundergoingproceduresknowntobeassociatedwitha
highincidenceofthromboemboliccomplications.Rareallergicreactionscausedby
hypersensitivitytodextranhavebeenreported,andinfrequentfatalanaphylactic
reactionshavealsobeendescribed.Mostofthesereactionsoccurinpatientsnot
previouslyexposedtointravenousdextranandoccurearlyintheinfusionperiod.
Thecomplicationofdextranallergyisextremelyrare,andinpersonalexperiencewith
wellover500patientapplications,Ihaveneverseenthiscomplication.Ihavehad
experiencewithseveralpatientsinwhompulmonaryedema,renalshutdown,orboth
developedafterseveraldaysofcontinuousinfusionofdextran,butthishasbeen
reportedbyothers.54Thesepatientsusuallyhadmarginalrenalfunctiontobeginwithor
someunderlyingcardiacorpulmonarydisorder.Theuseofdextranislikewise
contraindicatedinchildrenbecauseithasbeendocumentedtocauseanincreasein
bleedingproblemsinyoungerpatients.
Manysurgeonsroutinelyusedextranafterelectiveortraumaticmicrovascular
procedures.Therecommendeddoseinadultsis500mLofdextran40innormalsaline
givenoveraperiodof5to6hoursoncedailyfor3to5days.Othermicrosurgeons
insteadadministerthe500mLofdextranslowlyovera24hourperiod.Becausethepeak
antithromboticeffectofdextranispresent4hoursafterinfusion,theinitialdoseshould
bestartedbeforebeginningtheanastomosisformaximumeffect.Becauseofitslackof
provenefficacyandpotentialcomplications,Idonotusedextranroutinelyanymorein
microsurgery.Ihavenotnotedanyincreaseinanastomoticthrombosiswithits
discontinuation.

Prostaglandins
Certainprostaglandinsmightbeusefulforpreventingprimaryplateletaggregation.They
havebeenstudiedexperimentallybothaslocalandassystemicagents.18,60Therehave
beenafewclinicalcasereportsoftheuseoftheseagentsforrecurrentthrombosisofan
anastomosis.92Theusefulnessofprostaglandins,however,hasyettobeprovedin
microsurgicalreconstruction.
Insummary,themostwidelyuseddrugregimenseemstobeaspirinanddextran.In
situationsinwhichdamagedvesselsarepresumedorknowntobepresent,suchascrush
andavulsioninjuries,heparinisoftenaddedandcontinueduntiltheendothelium
regenerates.Endothelialregenerationbeginsveryearly,andforsmallareascoveragemay
becompletedquickly.Inpatientswithmoreseveretrauma,suchasthecrushand

avulsiontype,aslongas5to7daysmayberequiredtosealtheendotheliumandthe
anastomoticsite.Thecomplicationsofheparinization,includingbleedingandhematoma
formation,havebeendiscussedpreviously.Atpresent,however,unlessthereareseverely
diseasedordamagedvesselsorintraoperativethrombosis,Iuseonlyintraoperative
heparinizedirrigationandpostoperativeaspirintherapyforroutinemicrovascularcases.

Vasodilators
TopicalandIntraarterialAgents
Vasodilationmaybeaccomplishedbytopical,intraarterial,orsystemicdrug
administration.Topicalvasodilatorsareapplieddirectlyontothevesselsduring
dissectionorafterrepair.Lidocaineisthemostcommonlyusedagent,butprobablyin
strengthstoolowtohavemuchbeneficialeffect.Concentrationsof4%to20%are
recommendedbasedonexperimentalstudies,butaboveaconcentrationof10%therecan
beproblemswithtoxicity.Igenerallyusea4%solution,whichisreadilyavailablein
mostoperatingrooms.Inrareinstances,pathologicvasoconstrictionthatthreatens
viabilityoftherevascularizedtissuecanoccurandmayberefractorytomethods
previouslymentioned.Inthesecircumstances,papaverinemaybeinjectedintothedistal
vessel,whichmayreleasethevasospasm.Intraarterialinjectionoftolazoline,
nitroglycerin,reserpine,orguanethidinemayalsobehelpfulinthesesituations.Reports
ofclinicaluseoftheseagentsaresparse,andthesereportsshouldbereferredtoregarding
thedosagesandmethodofadministration.

SystemicAgents
Phenoxybenzamine(Dibenzyline)isalongactingadrenergicblockingagentthat
increasescardiacoutput.Itincreasesbloodflowtotheskinandhasbeenusedtotreat
vasospasticdisorderssuchasRaynaudssyndromeandfrostbitesequelaeandto
improvethesurvivalofmarginaltissueofpedicleflaps.Orthostatichypotensionisthe
mostcommonsideeffect.Theinitialdoseis10mg/dayorally,whichmaybeincreased
astolerated.Inasupinepatientafterflaptransferorreplantation,10or20mgorally
twoorthreetimesadayisusuallywelltoleratedaslongasthepatientissupine.
Nifedipine(Procardia)isacalciumchannelblockerthatisprobablythedrugofchoice
forcoldintoleranceaftersuccessfuldigitorextremityreplantation.Itisofteneffective
iftakenjustbeforecoldstress.Itisavailableinanextendedreleaseformandcanbe
givenasaninitialdoseof30mg,usuallyatbedtime.Upto60mg/daymayberequiredto
relievesymptoms.Nifedipineisgenerallywelltoleratedbutmustbeusedwithcautionin
smallerindividualsandthosewithlowbloodpressure.
Chlorpromazine(Thorazine)hasawidevarietyofactions,includingadrenergic
blockade,antiinflammatoryproperties,antiplateleteffects,andcellmembrane
stabilization.Alltheseactionsaidinincreasingthetoleranceoftissuetoischemia.I
routinelyusethisagentafterreplantationandfreeflapsurgery.However,noclinical

studiesafterreplantationorfreetissuetransferareavailable.Therecognizedsedative
effectofchlorpromazineisprobablyalsobeneficial;therecommendeddoseis25mg
orallyorintramuscularlyevery6to8hours.Thisagentshouldbeusedwithcautionin
elderlypatientsorthosewithrespiratoryproblems.

FibrinolyticAgents
Urokinase,streptokinase,andtissueplasminogenactivator(tPA)havebeen
recommendedaspossiblybeingbeneficialinsalvagingafailingreplantortissuetransfer.
Lifethreateningallergicreactionsandbleedingcomplicationsmayoccur,andan
experiencedhematologistshouldprobablybeconsultedformanagementofthese
medications.Treatmentmustbeadministeredearlyifitistobeeffective,andsalvageof
failingreplantshasbeenreportedwiththesetechniques(RussellRC,personal
communication,1987).Likewise,theseagentshavebeenshowntobeofbenefitin
patientsinwhomflowcannotbeestablishedintoareplanteddigitorflap.Insuchcases
therehasprobablybeendistalembolizationofclot,whichthethrombolyticagent
dissolvestoallowrestorationofflow.Thesedrugsmustgenerallybeadministeredby
intraarterialcatheterization,andweusuallyconsultahematologistorradiologistforthe
appropriatedosages.LocaluseoftPAinreplantationhasbeenadvocated,bothfor
arterialandvenousthrombosis.
Researchisbeingdonetoidentifydrugsthataremorespecificintheireffectsonthe
microcirculation.Thismaysomedayallowprotectionoftheanastomosiswithoutthe
threatofbleedingcomplications.

NERVEREPAIR

MethodsofSuturing
Muchhasbeenwrittenabouttherelativeadvantagesofperineurial(fascicular)and
epineurialsutures.Spinneroffersanexcellentreviewinwhichhestatesthatfascicular
sutureisusefulindistalmedianandulnarrepairsandemphasizesthatthemost
importantcauseoffailureofsutureisinadequateresectionofinjurednervebackto
healthytissue.123Icontinuetousefascicularsutureforprimaryrepairofclean
transectionsofmosttrunknervesandexpecttousegroupfascicularsutureindelayed
cases.Ithinkthatrepairoftheepineuriumisimportantbecauseitaddsstrengthtothe
repair,sealsthenervetrunkofffromadjacenttissue,andrestores,asmuchaspossible,a
glidingplanebetweenthenervetrunksandadjacenttissue.
Muchhasbeenwrittenabouttechniquesofnervesuture.Ithinkthatoperatingsurgeons
shouldusetheirownjudgmentaboutwhatisappropriatewhilealwaysbearinginmind
theprimaryaimofrepair,whichistocoapt,asaccuratelyaspossible,healthynerve
withoutundueinterferenceoftheperineuriumorbloodsupplyandwithoutunduetension
(seelater).
Protectionoftherepairbycarefullyregulatedflexionofadjacentjointsisessential.
Surgeonsshouldusethetechniquewithwhichtheyaremostconfidentandismost
appropriate.Innerverepairingeneral,Ifindithardtosaythatthereisarightora
wrongwayofdoingthings.However,asBrushartsaysincommentingonthetimingof
repair,Inperipheralnervesurgery,thefirstrepairmustbethebestrepairpossible.23

PreparationoftheNerveBed
Preparationofthebedforthenerverepairisofutmostimportance.Therepairednerve
mustnotbelefttolieagainstanakedtendon;thesynoviummustbedrawntogether.
Similarly,laceratedmusclebellyisaveryunfavorablebedforanerverepair,and
rotationofeitheradjacentsynoviumorundamagedfatshouldbedone.

DirectSuture
Iusethetermsprimarysuturewhentheoperationisperformedwithin5daysofinjury
anddelayedprimarysuturewhenupto3weekshaspassed.Someresection,ofamilli
meterorsoofthenervestump,isalwaysnecessaryafterthepassageofafewdays,even
incasesofcleansectioningwithaknifeorrazor.Secondarysutureisusedforrepairs
performed3weeksorlongerafterinjury,anditinvolvesresectionofneuroma
proximallyandgliomadistally.
Themedianandulnarnervesarecommonlysectionedatthewristintidywounds.This

istheidealcaseforprimarysuture.
1. Thelimbispreparedwithanaqueousantimicrobialsolution.Iodineand
alcoholbasedpreparationsareavoided.
2. Atourniquetcuffisplacedaboutthearmbutisnotinflateduntilthelimbhas
beenpreparedandexposurecanbestarted.Thecuffremainsinflatedforthe
exposureandidentificationofalldividedstructures,aswellasideallyfor
repairoftheflexortendons,theirsynovium,andtheradialandulnarartery,
butIalwaysreleasethetourniquetat1hour.Inalloperationsthetourniquetis
releasedbeforenerverepairorgrafting.Repairofthenervetrunksisdonelast
afterrepairofothertissues.Bleedingfromepineurialvesselsalongthesurface
ofthemediannerveorevenwithinitssubstancecanbetroublesome,andif
thisfailstorespondtogentlepressure,carefuluseofbipolardiathermysetat
lowamplitudeisnecessary.
3. Theincisionisextendedsothatalldividedstructurescanbedisplayed.Ina
deepwoundwithdamagetothearteriesofthewrist,Iopenthecarpaltunnel
tohelpidentifyinjuredstructuresandtodiminishtheriskoflatercom
pressionofthemediannervewithinthetunnel(Figure32.8).
4. Thetendonsarerepairedwithcoreandepitendinoussuture.Repairofthe
synoviumaroundeachtendonis,Ibelieve,anessentialsteptodiminish
adhesionsbetweenthetendonandthenerverepair.Thenervemustbeper
mittedtoglidebetweensynoviallayers.Arteriesarerepairedwithinterrupted
80nylonsutures.
5. Theadventitialmesoneurialtissueispushedbackfromeachstumptoexpose
thetrueepineurium(Figure32.9).Matchingofthenervestumpsisaidedby
thevaryingsizeofthefasciclesandbytheorientationofepineurialblood
vessels.Asketchofeachnervefacehelpsinorientationandplanningsuture
placement.Matchedbundles,identifiedbytheirsizeandbytheirpositionin
thenerve,aredrawntogetherwithperineurial100nylonsutures(Figure
32.10).Forthemediannerve,betweensixandeightkeybundleswillbe
suturedinthismannertocoaptthenervefacesasaccuratelyaspossible.The
repairisthencompletedbypassing90nylonsuturesthroughtheperineu
riumandepineurium(Figure32.11).Thenervecanberotatedonasaline
soakeddentalswab,firstfromonesideandthenfromtheothersothatthe
wholecircumferenceofthenerveisaccessible.Withthismethodbetween18
and25suturesarenecessarytorepairtheadultmediannerveatthewrist.

EpineurialRepair
Thebundlesareorientedaswellaspossible,andtheepineuriumisunitedwithtwo
lateral80nylonsutures,theendsofwhichareleftlong.Repairoftheanteriorfaceis
completedwiththreeorfourmore70nylonsutures.Thenerveisthenrotatedby
manipulationofthelateralsuturessothattheposteriorepineuriumcanbeunited.
Itisinthefreshwoundthatthedisadvantagesofepineurialrepairarebestshown.The

bundlesmaytwistaroundwithintheepineurium.