Beth A. Bergman, William A. Zamboni, and Richard E. Brown
MICROVASCULAR ANASTOMOSIS OF A RECTUS ABDOMINIS FREE FLAP INTO A PROSTHETIC
ABSTRACT Distal bypass grafts are frequently employed to revascularize lower extremities and to replace major peripheral vessels following excision of large soft-tissue or bone tumors. Autogenous vein grafts are generally used for such bypasses, when available. Large wounds associated with peripheral vascular disease or excision of massive tumors frequently require concomitant free-tissue transfers. Anastomosis of a freetissue transfer pedicle to a vein bypass graft has been reported. The first successful case of an anastomosis of a flap pedicle to a Gore-tex bypass graft is presented. Current management of severe peripheral vascular disease and large soft-tissue or bone tumors of the extremities includes aggressive surgical attempts at limb salvage. Reconstruction of such cases often involves extensive vascular bypass procedures, as well as microvascular free-tissue transfers. Autogenous saphenous vein graft is the preferred conduit for arterial reconstruction in the lower extremity. However, the use of a prosthetic vascular graft may become necessary when autogenous vein graft is unavailable. Although successful anastomosis of microvascular freetissue transfers into saphenous vein bypass grafts has been described, 12 direct anastomosis of a free flap pedicle into a prosthetic graft has not been reported. We present a case in which a microvascular free-flap anastomosis to a Gore-tex arterial bypass graft was successfully performed.
CASE REPORT A 54-year-old white male presented with a severalyear history of a slowly enlarging left-thigh mass. On
physical examination, he was found to have a massive left-thigh mass (Fig. 1A) which measured approximately 87 cm at its largest circumference and 53 cm in length, extending from the level of the anterior superior iliac spine to just below the knee. A 6-cm ulceration was noted in the skin overlying the mass (Fig. IB). The lower leg and foot were neurovascularly intact. The mass on CT scan appeared separated from bone by soft tissue; however, a bone scan revealed increased uptake around the distal aspect of the femur. An open biopsy was consistent with a well-differentiated chondrosarcoma. Arteriography confirmed tumor neovascularity and encasement of the femoral artery, but a metastatic workup was negative. A radical tumor excision was performed, including resection of the superficial femoral vessels from the level of the common femoral bifurcation to the belowknee popliteal space, as well as resection of the medial cortex and condyle of the distal femur (Fig. 2). The distal femur was reconstructed with a banked allograft and iliac cancellous bone graft (Fig. 3). Bilateral saphenous vein grafts were used to reconstruct a largediameter femoral vein, and arterial reconstruction was
Division of Plastic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois Reprint requests: Dr. Brown, Chief, Section of Hand Surgery, Division of Plastic Surgery, Southern Illinois University School of Medicine, P.O. Box 19230, Springfield, IL 62794-9230 Accepted for publication July 18,1991 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
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VASCULAR BYPASS GRAFT
JANUARY 1992
Figure 1. A, Massive chondrosarcoma arising from distal femur. B, Tumor ulceration.
\ 10
Figure 2. After tumor excision. Vascular clamps on proximal femoral vessels.
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JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 1
FREE-FLAP INFLOW FROM GORE-TEX GRAFT/BERGMAN, ZAMBONI, BROWN
performed using an 8-mm Gore-tex graft (see Fig. 3). Complete coverage of the bone allograft and the Goretex graft necessitated a rectus muscle free-tissue transfer. To facilitate complete coverage of the bone allograft and Gore-tex graft, an end-to-side anastomosis of the pedicle artery to the Gore-tex graft was performed, using a running 9-0 nylon suture (Fig. 4). Similarly, the inferior epigastric vein was anastomosed end-to-side to the reconstructed femoral vein. The flap was inset and covered with a split-thickness skin graft. (Fig. 5) No flap problems occurred postoperatively. Final pathology was consistent with a Grade 3 chondrosarcoma. Three months postoperatively, all wounds were healed and the patient was started on ambulation (Fig. 6). Color-flow Doppler studies showed patency of
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Figure 3. Reconstructed femoral artery and vein and plated distal femur allograft.
the pedicle-Gore-tex anastomosis and distal flow into the flap. Postoperative local radiotherapy was initiated at three months.
DISCUSSION Severe peripheral vascular disease, previously requiring amputation, may now be treated with more aggressive limb-salvage procedures. The increased success of distal vascular bypass procedures in recent years has expanded their frequency. In addition, the presence of concomitant non-healing wounds often necessitates microvascular free-tissue transfers for wound closure. Similarly, many large soft-tissue and
Figure 4. End-to-side anastamosis of inferior epigastric artery to Gore-tex graft and inferior epigastric vein to reconstructed femoral vein.
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JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 1
JANUARY 1992
bone tumors, previously treated with amputation, may now be managed by extensive resection and reconstruction. Here again, revascularization and microvascular free-tissue transfer for coverage may be necessary. Colen1 and Shestak and colleagues2 noted the successful management of lower-extremity wounds secondary to peripheral vascular disease, using microsurgical free-tissue transfers with anastomosis of the flap artery into the saphenous vein bypass grafts. However, when autogenous vein is not available, the use of prosthetic vascular material becomes necessary. The ability to perform successful microvascular anastomosis into this prosthetic material will, in many cases, be essential. In the present case, direct end-to-side anastomosis of a rectus abdominis pedicle into a Gore-tex arterial bypass graft was easily performed without complication.
REFERENCES 1. 2.
Figure 6. Three months postoperatively.
Colen LB: Limb salvage in the patient with severe peripheral vascular disease: The role of microsurgical free-tissue transfer. Plast Reconstr Surg 79:389, 1987 Shestak KC, Fitz DG, Newton ED, Swartz WM: Expanding the horizons in treatment of severe peripheral vascular disease using microsurgical techniques. Plast Reconstr Surg 85: 406, 1990
ADDITIONAL REFERENCES Chowdory RP, Celani VI, Goodreow IJ, et al: Free-tissue transfers for limb salvage utilizing in situ saphenous vein bypass conduit as the inflow. Plast Reconstr Surg 87:529, 1991 Greenwald LL, Comerota AJ, Mitra A, et al: Free vascularized tissue transfer for limb salvage in peripheral vascular disease. Ann Vase Surg 4:244, 1990
12
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Figure 5. Immediate postoperative appearance.
MICROVASCULAR ANASTOMOSIS OF A RECTUS ABDOMINIS FREE FLAP INTO A PROSTHETIC
ABSTRACT Distal bypass grafts are frequently employed to revascularize lower extremities and to replace major peripheral vessels following excision of large soft-tissue or bone tumors. Autogenous vein grafts are generally used for such bypasses, when available. Large wounds associated with peripheral vascular disease or excision of massive tumors frequently require concomitant free-tissue transfers. Anastomosis of a freetissue transfer pedicle to a vein bypass graft has been reported. The first successful case of an anastomosis of a flap pedicle to a Gore-tex bypass graft is presented. Current management of severe peripheral vascular disease and large soft-tissue or bone tumors of the extremities includes aggressive surgical attempts at limb salvage. Reconstruction of such cases often involves extensive vascular bypass procedures, as well as microvascular free-tissue transfers. Autogenous saphenous vein graft is the preferred conduit for arterial reconstruction in the lower extremity. However, the use of a prosthetic vascular graft may become necessary when autogenous vein graft is unavailable. Although successful anastomosis of microvascular freetissue transfers into saphenous vein bypass grafts has been described, 12 direct anastomosis of a free flap pedicle into a prosthetic graft has not been reported. We present a case in which a microvascular free-flap anastomosis to a Gore-tex arterial bypass graft was successfully performed.
CASE REPORT A 54-year-old white male presented with a severalyear history of a slowly enlarging left-thigh mass. On
physical examination, he was found to have a massive left-thigh mass (Fig. 1A) which measured approximately 87 cm at its largest circumference and 53 cm in length, extending from the level of the anterior superior iliac spine to just below the knee. A 6-cm ulceration was noted in the skin overlying the mass (Fig. IB). The lower leg and foot were neurovascularly intact. The mass on CT scan appeared separated from bone by soft tissue; however, a bone scan revealed increased uptake around the distal aspect of the femur. An open biopsy was consistent with a well-differentiated chondrosarcoma. Arteriography confirmed tumor neovascularity and encasement of the femoral artery, but a metastatic workup was negative. A radical tumor excision was performed, including resection of the superficial femoral vessels from the level of the common femoral bifurcation to the belowknee popliteal space, as well as resection of the medial cortex and condyle of the distal femur (Fig. 2). The distal femur was reconstructed with a banked allograft and iliac cancellous bone graft (Fig. 3). Bilateral saphenous vein grafts were used to reconstruct a largediameter femoral vein, and arterial reconstruction was
Division of Plastic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois Reprint requests: Dr. Brown, Chief, Section of Hand Surgery, Division of Plastic Surgery, Southern Illinois University School of Medicine, P.O. Box 19230, Springfield, IL 62794-9230 Accepted for publication July 18,1991 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
Downloaded by: University of Iowa Libraries. Copyrighted material.
VASCULAR BYPASS GRAFT
JANUARY 1992
Figure 1. A, Massive chondrosarcoma arising from distal femur. B, Tumor ulceration.
\ 10
Figure 2. After tumor excision. Vascular clamps on proximal femoral vessels.
Downloaded by: University of Iowa Libraries. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 1
FREE-FLAP INFLOW FROM GORE-TEX GRAFT/BERGMAN, ZAMBONI, BROWN
performed using an 8-mm Gore-tex graft (see Fig. 3). Complete coverage of the bone allograft and the Goretex graft necessitated a rectus muscle free-tissue transfer. To facilitate complete coverage of the bone allograft and Gore-tex graft, an end-to-side anastomosis of the pedicle artery to the Gore-tex graft was performed, using a running 9-0 nylon suture (Fig. 4). Similarly, the inferior epigastric vein was anastomosed end-to-side to the reconstructed femoral vein. The flap was inset and covered with a split-thickness skin graft. (Fig. 5) No flap problems occurred postoperatively. Final pathology was consistent with a Grade 3 chondrosarcoma. Three months postoperatively, all wounds were healed and the patient was started on ambulation (Fig. 6). Color-flow Doppler studies showed patency of
Downloaded by: University of Iowa Libraries. Copyrighted material.
Figure 3. Reconstructed femoral artery and vein and plated distal femur allograft.
the pedicle-Gore-tex anastomosis and distal flow into the flap. Postoperative local radiotherapy was initiated at three months.
DISCUSSION Severe peripheral vascular disease, previously requiring amputation, may now be treated with more aggressive limb-salvage procedures. The increased success of distal vascular bypass procedures in recent years has expanded their frequency. In addition, the presence of concomitant non-healing wounds often necessitates microvascular free-tissue transfers for wound closure. Similarly, many large soft-tissue and
Figure 4. End-to-side anastamosis of inferior epigastric artery to Gore-tex graft and inferior epigastric vein to reconstructed femoral vein.
11
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 1
JANUARY 1992
bone tumors, previously treated with amputation, may now be managed by extensive resection and reconstruction. Here again, revascularization and microvascular free-tissue transfer for coverage may be necessary. Colen1 and Shestak and colleagues2 noted the successful management of lower-extremity wounds secondary to peripheral vascular disease, using microsurgical free-tissue transfers with anastomosis of the flap artery into the saphenous vein bypass grafts. However, when autogenous vein is not available, the use of prosthetic vascular material becomes necessary. The ability to perform successful microvascular anastomosis into this prosthetic material will, in many cases, be essential. In the present case, direct end-to-side anastomosis of a rectus abdominis pedicle into a Gore-tex arterial bypass graft was easily performed without complication.
REFERENCES 1. 2.
Figure 6. Three months postoperatively.
Colen LB: Limb salvage in the patient with severe peripheral vascular disease: The role of microsurgical free-tissue transfer. Plast Reconstr Surg 79:389, 1987 Shestak KC, Fitz DG, Newton ED, Swartz WM: Expanding the horizons in treatment of severe peripheral vascular disease using microsurgical techniques. Plast Reconstr Surg 85: 406, 1990
ADDITIONAL REFERENCES Chowdory RP, Celani VI, Goodreow IJ, et al: Free-tissue transfers for limb salvage utilizing in situ saphenous vein bypass conduit as the inflow. Plast Reconstr Surg 87:529, 1991 Greenwald LL, Comerota AJ, Mitra A, et al: Free vascularized tissue transfer for limb salvage in peripheral vascular disease. Ann Vase Surg 4:244, 1990
12
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Figure 5. Immediate postoperative appearance.
