Accepted Manuscript Title: Retrospective cohort study of combined approach for trunk reconstruction using arteriovenous loops and free flaps Author: Andreas Arkudas, Raymund E. Horch, Susanne Regus, Alexander Meyer, Werner Lang, Marweh Schmitz, Anja M. Boos, Ingo Ludolph, Justus P. Beier PII: DOI: Reference:
S1748-6815(17)30360-1 http://dx.doi.org/doi: 10.1016/j.bjps.2017.08.025 PRAS 5442
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received date: Accepted date:
19-4-2017 13-8-2017
Please cite this article as: Andreas Arkudas, Raymund E. Horch, Susanne Regus, Alexander Meyer, Werner Lang, Marweh Schmitz, Anja M. Boos, Ingo Ludolph, Justus P. Beier, Retrospective cohort study of combined approach for trunk reconstruction using arteriovenous loops and free flaps, Journal of Plastic, Reconstructive & Aesthetic Surgery (2017), http://dx.doi.org/doi: 10.1016/j.bjps.2017.08.025. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Retrospective Cohort Study of Combined Approach for Trunk Reconstruction using Arteriovenous Loops and Free Flaps
#
Andreas Arkudas, M.D.¹*, Raymund E. Horch, M.D.¹, Susanne Regus, M.D.², Alexander Meyer, M.D.², Werner Lang, M.D.², Marweh Schmitz, M.D.¹, Anja M. Boos, M.D.¹, Ingo Ludolph, M.D.¹, Justus P. Beier, M.D.¹
¹ Department of Plastic and Hand Surgery, University Hospital Erlangen, FriedrichAlexander-University of Erlangen-Nürnberg (FAU), Erlangen, Germany ² Department of Vascular Surgery, University Hospital Erlangen, Friedrich-AlexanderUniversity of Erlangen-Nürnberg (FAU), Erlangen, Germany *
To whom correspondence should be addressed
Corresponding author: Andreas Arkudas, M. D. Department of Plastic and Hand Surgery University Hospital of Erlangen Friedrich-Alexander-University of Erlangen-Nürnberg (FAU) Krankenhausstrasse 12, 91054 Erlangen, Germany Phone:
+49 (0) 9131 85 33277
1 Page 1 of 26
Fax:
+49 (0) 9131 85 39327
e-mail:
[email protected]
# Parts of this work have been presented at the 38 th Congress of German Society for Microsurgery of Peripheral Nerves and Vessels (2016 Linz, Austria), at the 47 th annual meeting of the German society of plastic, reconstructive and aesthetic surgeons (DGPRÄC) and 21st annual meeting of the German Association of Aesthetic Plastic Surgeons (VDÄPC) (2016 Kassel, Germany) and at the 134 th Congress of German Society of Surgery (2017 Munich, Germany)
2 Page 2 of 26
Abstract Defect reconstruction of the trunk can be performed using microsurgical free flap transplantation. In cases of missing or inappropriate recipient vessels, microsurgical defect reconstruction of the trunk can be achieved by combining free flaps with arteriovenous loops. Here we present our 5-year experience of trunk reconstruction using AV loops and free flaps in a retrospective evaluation. We analyzed 32 cases of trunk reconstruction using a combined approach of free flap transplantation and arteriovenous loops between 2011 and 2016 regarding postoperative complications and perioperative course. Twenty-one patients suffered from sternal defects, 4 from presacral defects, 3 patients presented with lateral chest wall defects, 2 patients suffered from lumbosacral defects, 1 patient had a gluteal defect and 1 patient a defect at the clavicle. In all cases, free flap transplantation and arteriovenous loop creation were performed in a two-stage procedure. There were 8 thromboses of the arteriovenous loops with 4 flap failures. Only 1 flap loss was located in the sternal region, whereas one presacral flap and both lumbosacral flaps were lost. Reconstruction of large soft tissue defects of the trunk by a combined approach with an arteriovenous loop creation and consecutive free flap transplantation represents a reliable procedure in ventral and posterior cranial localization, whereas in the caudal posterior region, AV loop thrombosis can occur. Therefore, to minimize flap loss, a twostage procedure should be performed. Keywords:
Arteriovenous
loop;
Free
Flap
Transplantation;
Microsurgical
Transplantation; Trunk Reconstruction
3 Page 3 of 26
Introduction: Microsurgical transplantation of free flaps represents a safe and reliable technique for defect reconstruction even in large defects
1-3
. The microsurgical anastomosis of the
donor vessels at the recipient site requires adequate recipient vessels to ensure postoperative flap survival. In some cases, recipient vessels are missing or inadequate. In these situations free flap transplantation can still be achieved by means of arteriovenous loops (AV loops) using autologous vein grafts 4. In extremity revascularization, AV loop creation and subsequent free flap transfer represents one possible technique for limb salvage besides bypass or inflow reconstruction
5
.
Multiple studies have been published regarding these kinds of defect coverages in the extremities
6-8
. Using a combined approach of AV loops and microsurgical free
flap transplantation, defects in the trunk area can also be reconstructed. Although perforator based local flaps represent a possible defect reconstruction technique in selected cases in nearly every possible location 9, there are cases of complex tissue defects that require microsurgical free flap coverage
10
. Reasons for this can be the
size of the defect or inadequate perforators/recipient vessels due to compromised surrounding tissue. In this retrospective study we present our experiences with defect coverage using an AV loop and secondary microsurgical free flap transplantation in the trunk area with particular focus on AV loop patency and flap survival dependent on defect localization.
Materials and Methods: The study obtained ethical approval from the Ethical Committee of the University of Erlangen-Nürnberg (FAU) (reference number 160_17 Bc). Also, the authors adhered 4 Page 4 of 26
to the STROBE guidelines. Between January 2011 and July 2016, we performed defect coverage in the trunk region of 32 patients using arteriovenous loops and free flaps. The transplantation was always achieved in a two-stage procedure in an interdisciplinary approach. Firstly, the vascular surgeon created the arteriovenous loop, using an autologous great saphenous vein graft of the thigh anastomosed to a main arterial and venous vascular axis in an end-to-side fashion. Afterwards, flap transplantation was carried out in a secondary procedure. The reconstructions were reviewed regarding choice of flap, anastomosed main vascular axis for AV loop creation, defect entity and early postoperative complications. Patency of the AV loop and flap survival in the early postoperative course with regard to the defect localization were the main outcome variables of the study. Defect localization on the trunk was divided into ventral and posterior defects, with both groups being subdivided into cranial and caudal.
Results: The mean age of the patients was 57 years (ranging from 31 – 87 years), with 18 male and 14 female patients (Figure 1). The mean operation time for the flap transplantation was 293 min. (± 99 min.). 21 of 32 defects were located in the sternal region, one at the clavicle (all 22 classified as ventral cranial), 4 of the 7 dorsal caudal defects were located presacral (cavities ventral of the os sacrum), 2 lumbosacral and 1 gluteal. Three patients also suffered from lateral chest wall defects (Figure 2). Twenty-one AV loops were anastomosed in an end-to-side fashion to the subclavian vascular axis, 7 to the femoral vessels and 4 to the axillary vessels. There were 8 AV 5 Page 5 of 26
loop thromboses detectable, 4 occurred in the AV loops anastomosed to the femoral vessels, only 2 in the AV loops anastomosed to the subclavian vessels and 1 anastomosed to the axillary vessels (Figure 3). One AV loop was created between the cephalic vein and the common carotid artery. This AV loop was subsequently thrombosed and no flap transplantation was performed. In all cases, free flap transplantation and arteriovenous loop creation were performed in a two-stage procedure with AV loop creation in the first operation and consecutive free flap transplantation. The mean interval between these two operations was 9.5 days with the shortest interval of 2 days and the longest of 21 days (Figure 4). In 11 cases a myocutaneous vastus lateralis flap was transplanted, all for coverage of sternal defects (Figure 5). Twelve patients received a latissimus dorsi flap, one of them as a muscle sparing flap and one as a combined latissimus dorsi/parascapular flap. Seven patients were treated with a vertical rectus abdominis myocutaneous (VRAM) flap. Of the 22 patients with cranioventral defects, the majority (20 patients) presented with sternal defects resulting from sternal osteomyelitis, 1 patient was diagnosed with a metastasis of a cervix carcinoma, located at the anterior chest wall, and 1 patient presented with a defect at the cranial chest wall because of a pseudarthrosis of the clavicle (Figure 6). One patient died between AV loop creation and flap transplantation due to worsening of his overall cardiac condition. All lateral chest wall defects were covered using a previously created axillary arteriovenous loop and contralateral latissimus dorsi flap transplantation (Figure 7). The lateral chest wall defects were caused by a metastasis of an esophageal carcinoma, a metastasis of a thymic carcinoma and a fistula after multiple operations
6 Page 6 of 26
of a gastrointestinal stromal tumor. One patient suffered from a postoperative fistula which had to be revised operatively. Three patients with the presacral defects were treated because of rectal carcinomas, one patient had a sigmoid carcinoma (Figure 8). These four patients suffered of multiple abdominal operations previously combined with irradiation and chemotherapy. For presacral reconstruction femoral arteriovenous loops were created with consecutive free flap transfer. In one case the femoral arteriovenous loop had a venous thrombosis after free flap transplantation leading to flap loss. The one patient with the gluteal defect presented with a desmoid tumor recurrence. In this case two femoral arteriovenous loops were created but, due to postoperative loop thrombosis, defect coverage was finally achieved using two local flaps (S-GAP perforator flap and rotational flap) (Figure 9). One of the patients with a lumbosacral defect was diagnosed with a metastasis of a rectal carcinoma, the other patient suffered from a wound healing disorder after spinal stenosis surgery. Both AV loops created for defect coverage of the two lumbosacral defects (one to the axillary vessels with an intraoperative lengthening of the AV loop using another saphenous graft and one to the femoral vessels) showed postoperative thromboses, leading to consecutive flap losses. There was a total of four flap losses after secondary flap transplantation. There were four resections of the flap skin paddles due to inadequate vascularization and three tip necrosis of the flaps.
Discussion:
7 Page 7 of 26
Complex tissue defects in the trunk area are challenging for every reconstructive surgeon. Although some defects can be covered using perforator or other local flaps, sometimes free flap transfer is required. Arteriovenous loops can allow microsurgical free flap transplantation in areas without suitable recipient vessels 4. Main vascular axes in the trunk area for anastomosing the AV loop are the femoral vessels, subclavian vessels and axillary vessels. We have already published our experiences with AV loops and free tissue transfer in sternal wounds
11
and limb ischemia
6
as
well as our general experience with AV loops and free flaps independent of the area of reconstruction
12
. In this retrospective study, we focus on defects in the trunk
region. In our experience patency of the arteriovenous loops strongly correlates with the localization of the defect. Defects located on the ventral side, e.g. for sternal reconstructions usually require an AV loop anastomosed to the subclavian vessels. In our experience this kind of AV loop shows high patency rates, since only 2 of 21 AV loops (9.5%) were thrombosed, leading to 1 flap loss (4.8%). In previous studies in our department, there were no AV thromboses detectable in sternal AV loops
11
.
Reichenberger et al. described the so-called CTA loop, using the cephalic vein anastomosed to the thoracoacromial artery for sternal reconstructions
13
. In our
experience with the CTA loop from previous studies, we had much higher complication rates compared to the subclavian AV loop. In one case of this study, we anastomosed the cephalic vein to the common carotid artery, this AV loop was also thrombosed. Dornseifer et al. reported the use of the gastroepiploic vessels as recipient vessels for free flap transplantation to avoid AV loop creation
14
. In our
opinion, AV loop creation is a fast and less invasive procedure compared to
8 Page 8 of 26
harvesting the gastroepiploic vessels and hereby transforming a one-cavity procedure into a two-cavity procedure with an increased perioperative mortality. We also performed defect reconstruction in the cranial posterior trunk and the lateral chest wall using arteriovenous loops in cases, where pedicled flaps were not an option and recipient vessels were lacking. In this study we successfully treated three patients suffering from lateral chest wall due to tumor metastasis or fistula. All AV loops anastomosed to the axillary vessels were patent without any vascular complications. Gazyakan et al. reported of a bilateral chest wall reconstruction using ALT and TFL flaps anastomosed to an arteriovenous loop based on the axillary vessels 15. Tukiainen et al. were also able to reconstruct chest wall defects using TFL flaps combined with arteriovenous loops anastomosed to the femoral artery
16
.
In our experience, the most challenging defect area proved to be the posterior caudal trunk region. Five of eight arteriovenous loops showed thromboses (62.5%) leading to three flap losses. It is worth mentioning that only the two-stage procedure prevented us from more flap failures, so not every AV loop thrombosis led to a flap loss. Despite revision of the AV loop, none of these flaps was salvaged in these cases. Seven AV loops were anastomosed to the femoral vessels, whereas one AV loop was created using long interposed saphenous vein grafts to the axillary vessels. The technique of using arteriovenous loops in combination with free flap transplantation to reconstruct defects in the lumbosacral localization was first described by Salibian et al. in 1983
17
. In 1986, Nahai et al. first described the same
operation as a complete one-stage procedure
18
. In our case, we chose the axillary
vessels as the main vascular supply for the AV loop to have the opportunity to perform a two-stage procedure. This caused longer saphenous grafts, accompanied by the risk of impaired flow characteristics, possibly leading to 9 Page 9 of 26
stasis and thrombosis. There were also other authors who described defect coverage of lumbosacral defects by a latissimus dorsi flap, by lengthening the vascular pedicle using vein grafts
19, 20
. Four of the seven AV loops anastomosed to
the femoral vessels showed thromboses postoperatively, leading to two flap losses. The AV loops were created in order to reconstruct presacral or gluteal defects. Earle described this procedure in 1990 for gluteal, sacral and posterior thigh defects
21
.
They had no AV loop thromboses in both presented cases, whereas in our experience this kind of AV loop has a high potential for pedicle thromboses. For presacral defects, the AV loop was placed in the medial thigh, whereas for gluteal reconstructions the AV loop was guided laterally along and superior to the iliac crest. In both positions, we detected AV loop thromboses, although the venous distal end of the saphenous graft was reanastomosed to the femoral vein to prevent kinking of the venous pedicle instead of leaving it orthotopically in situ. So whenever possible, we would recommend local flaps such as rotational or perforator flaps in the gluteal/presacral region. We always use a workhorse flap with a low flow resistance in combination with AV loops, because perforator flaps or flaps with a high flow resistance (such as the gracilis muscle flap) often showed pedicle thromboses in the past when combined with a high-flow AV loop. Others report on AV loops combined with perforator flaps such as ALTs or AMTs
20
. One patient received defect coverage using local flaps (S-
GAP, rotational flap) due to repetitive AV loop thromboses. However, in this young female patient, the two pedicled flaps used as a “salvage procedure” would not have been the first choice, due to the significant disfiguring caused in particular by the large rotational flap. On the other hand, the scars of the free flap and vein harvest would also be difficult to hide. 10 Page 10 of 26
We always chose a two-stage procedure with AV loop creation in the first operation and consecutive free flap transplantation after some days, as it increases the safety of the entire procedure in our opinion. We prefer an interval between one and two weeks to ensure patency of the AV loop. In our experience, intervals longer than two weeks lead to an increased fibrosis of the AV loop vessel walls, possibly due to the arterialization of the venous graft. This process renders venous anastomosis using a coupler device impossible, while on the other hand no further increase in patency safety will be achieved after more than two weeks. In this study there could have been up to four more flap failures due to AV loop thromboses when transplanted in a one-stage procedure. So, from our point of view, the additional operating time is justified by the increase in flap procedure safety.
Conclusions: Large defects located in the trunk region are challenging, especially when local flaps are not available to reconstruct the defect and recipient vessels for free flap transplantation are missing or inadequate. In these cases, creation of an arteriovenous loop can allow microsurgical free flap transfer to cover the defect. This procedure represents a reliable technique to reconstruct ventral and cranial posterior defects of the trunk in particular, whereas the caudal posterior area remains difficult due to increased AV loop thromboses. In this region, local flaps such as rotational or perforator flaps are the best option whenever possible.
Conflict of interest statement: None declared. 11 Page 11 of 26
Acknowledgements: Proof reading of the article was performed by “proofreading.de”. This study did not receive any specific grant from funding agencies in the public, commercial, or not-forprofit sectors.
References: 1. Ludolph I, Apel H, Horch RE, Beier JP. Treatment of a chronic vesicocutaneous fistula and abdominal wall defect after resection of a soft tissue sarcoma using a bipedicled latissimus dorsi and serratus anterior free flap. International journal of urology : official journal of the Japanese Urological Association. 2014;21:1178-80. 2. Boos AM, Beckmann MW, Horch RE, Beier JP. Interdisciplinary Treatment for Cutaneous Abdominal Wall Metastasis from Cervical Cancer with Resection and Reconstruction of the Abdominal Wall Using Free Latissimus Dorsi Muscle Flap: A Case Report. Geburtshilfe und Frauenheilkunde. 2014;74:574-8. 3. Beier JP, Horch RE, Kneser U. Bilateral pre-expanded free TFL flaps for reconstruction of severe thoracic scar contractures in an 8-year-old girl. Journal of plastic, reconstructive & aesthetic surgery : JPRAS. 2013;66:1766-9. 4. Taeger CD, Arkudas A, Beier JP, Horch RE. Emergency arterio-venous loop for free-flap defect reconstruction of the lower thigh with a post-irradiated and heavily infected wound. International wound journal. 2015;12:598-600. 5. Horch RE, Lang W, Arkudas A, Taeger C, Kneser U, Schmitz M, et al. Nutrient free flaps with vascular bypasses for extremity salvage in patients with chronic limb ischemia. The Journal of cardiovascular surgery. 2014;55:265-72. 12 Page 12 of 26
6. Meyer A, Goller K, Horch RE, Beier JP, Taeger CD, Arkudas A, et al. Results of combined vascular reconstruction and free flap transfer for limb salvage in patients with critical limb ischemia. Journal of vascular surgery. 2015;61:1239-48. 7. Cavadas PC. Arteriovenous vascular loops in free flap reconstruction of the extremities. Plastic and reconstructive surgery. 2008;121:514-20. 8. Sunar H, Aygit CA, Afsar Y, Halici U, Duran E. Arterial and venous reconstruction for free tissue transfer in diabetic ischemic foot ulcers. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2004;27:210-5. 9. Kneser U, Beier JP, Schmitz M, Arkudas A, Dragu A, Schmidt VJ, et al. Zonal perfusion patterns in pedicled free-style perforator flaps. Journal of plastic, reconstructive & aesthetic surgery : JPRAS. 2014;67:e9-17. 10. Allen RJ, Jr., Lee ZH, Mayo JL, Levine J, Ahn C, Allen RJ, Sr. The Profunda Artery Perforator (PAP) Flap Experience for Breast Reconstruction. Plastic and reconstructive surgery. 2016. 11. Taeger CD, Horch RE, Arkudas A, Schmitz M, Stubinger A, Lang W, et al. Combined free flaps with arteriovenous loops for reconstruction of extensive thoracic defects after sternal osteomyelitis. Microsurgery. 2016;36:121-7. 12. Meyer A, Horch RE, Schoengart E, Beier JP, Taeger CD, Arkudas A, et al. Results of combined vascular reconstruction by means of AV loops and free flap transfer in patients with soft tissue defects. Journal of plastic, reconstructive & aesthetic surgery : JPRAS. 2016;69:545-53. 13. Reichenberger MA, Harenberg PS, Pelzer M, Gazyakan E, Ryssel H, Germann G, et al. Arteriovenous loops in microsurgical free tissue transfer in reconstruction of central sternal defects. The Journal of thoracic and cardiovascular surgery. 2010;140:1283-7. 13 Page 13 of 26
14. Dornseifer U, Kleeberger C, Ehrl D, Herter F, Ninkovic M, Iesalnieks I. Arteriovenous Loop-Independent Free Flap Reconstruction of Sternal Defects after Cardiac Surgery. Journal of reconstructive microsurgery. 2016;32:506-12. 15. Gazyakan E, Engel H, Lehnhardt M, Pelzer M. Bilateral double free-flaps for reconstruction of extensive chest wall defect. The Annals of thoracic surgery. 2012;93:1289-91. 16. Tukiainen E, Leppaniemi A. Reconstruction of extensive abdominal wall defects with microvascular tensor fasciae latae flap. The British journal of surgery. 2011;98:880-4. 17. Salibian AH, Tesoro VR, Wood DL. Staged transfer of a free microvascular latissimus dorsi myocutaneous flap using saphenous vein grafts. Plastic and reconstructive surgery. 1983;71:543-7. 18. Nahai F, Hagerty R. One-stage microvascular transfer of a latissimus flap to the sacrum using vein grafts. Plastic and reconstructive surgery. 1986;77:312-5. 19. Di Benedetto G, Bertani A, Pallua N. The free latissimus dorsi flap revisited: a primary option for coverage of wide recurrent lumbosacral defects. Plastic and reconstructive surgery. 2002;109:1960-5. 20. Harry BL, Deleyiannis FW. Posterior trunk reconstruction using an anteromedial thigh free flap and arteriovenous loop. Microsurgery. 2013;33:416-7. 21. Earle AS, Feng LJ, Jordan RB. Long saphenous vein grafts as an aid to microsurgical reconstruction of the trunk. Journal of reconstructive microsurgery. 1990;6:165-9.
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Figure Legends: Figure 1 Demographic data
Figure 2 22 defects were located ventral cranial, divided into 21 sternal defects and 1 defect in at the clavicle. There were 3 defects at the lateral chest wall and 7 defects in the posterior caudal region (4 presacral, 2 lumbosacral, 1 gluteal).
Figure 3 Total number of AV loops and thrombosed AV loops
Figure 4 AV loop and flap data
Figure 5 Number of flaps regarding flap type.
Figure 6
15 Page 15 of 26
76-year-old patient suffering from sternal osteomyelitis. After radical debridement (A) an AV loop was created to the subclavian vessels. Defect reconstruction was performed using a myocutaneous vastus lateralis flap (B) anastomosed to the AV loop limbs (C, arrow). D) Arterial (x) and venous (*) anastomoses of the lateral circumflex flap vessels to the AV loop. E) Result 7.5 months postoperatively.
Figure 7 52-year-old patient with a metastasis of an esophageal carcinoma (A). Intraoperative view demonstrating the lateral chest wall defect with exposed Gore-Tex® patch (arrow) after resection (B). An arteriovenous loop (*) was created to the axillary vessels (C) following defect reconstruction using a contralateral latissimus dorsi flap. D) Clinical result 1 month postoperatively.
Figure 8 62-year-old patient with a cavity ventral of the os sacrum due to a resection of a rectal carcinoma (arrow) (A). An arteriovenous loop was placed in the medial thigh and anastomosed to the femoral vessels (B). Postoperative MR angiography displayed a patent AV loop (C). Defect coverage of the cavity was achieved using a latissimus dorsi flap anastomosed to the AV loop (D).
Figure 9
16 Page 16 of 26
47-year-old patient with a recurrence of a gluteal desmoid tumor. A) defect after tumor resection. B) gluteal perforators of left S-GAP flap. C) Postoperative result after defect reconstruction using S-GAP and rotational flap. D) Postoperative result after 1 year.
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S1748-6815(17)30360-1 http://dx.doi.org/doi: 10.1016/j.bjps.2017.08.025 PRAS 5442
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received date: Accepted date:
19-4-2017 13-8-2017
Please cite this article as: Andreas Arkudas, Raymund E. Horch, Susanne Regus, Alexander Meyer, Werner Lang, Marweh Schmitz, Anja M. Boos, Ingo Ludolph, Justus P. Beier, Retrospective cohort study of combined approach for trunk reconstruction using arteriovenous loops and free flaps, Journal of Plastic, Reconstructive & Aesthetic Surgery (2017), http://dx.doi.org/doi: 10.1016/j.bjps.2017.08.025. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Retrospective Cohort Study of Combined Approach for Trunk Reconstruction using Arteriovenous Loops and Free Flaps
#
Andreas Arkudas, M.D.¹*, Raymund E. Horch, M.D.¹, Susanne Regus, M.D.², Alexander Meyer, M.D.², Werner Lang, M.D.², Marweh Schmitz, M.D.¹, Anja M. Boos, M.D.¹, Ingo Ludolph, M.D.¹, Justus P. Beier, M.D.¹
¹ Department of Plastic and Hand Surgery, University Hospital Erlangen, FriedrichAlexander-University of Erlangen-Nürnberg (FAU), Erlangen, Germany ² Department of Vascular Surgery, University Hospital Erlangen, Friedrich-AlexanderUniversity of Erlangen-Nürnberg (FAU), Erlangen, Germany *
To whom correspondence should be addressed
Corresponding author: Andreas Arkudas, M. D. Department of Plastic and Hand Surgery University Hospital of Erlangen Friedrich-Alexander-University of Erlangen-Nürnberg (FAU) Krankenhausstrasse 12, 91054 Erlangen, Germany Phone:
+49 (0) 9131 85 33277
1 Page 1 of 26
Fax:
+49 (0) 9131 85 39327
e-mail:
[email protected]
# Parts of this work have been presented at the 38 th Congress of German Society for Microsurgery of Peripheral Nerves and Vessels (2016 Linz, Austria), at the 47 th annual meeting of the German society of plastic, reconstructive and aesthetic surgeons (DGPRÄC) and 21st annual meeting of the German Association of Aesthetic Plastic Surgeons (VDÄPC) (2016 Kassel, Germany) and at the 134 th Congress of German Society of Surgery (2017 Munich, Germany)
2 Page 2 of 26
Abstract Defect reconstruction of the trunk can be performed using microsurgical free flap transplantation. In cases of missing or inappropriate recipient vessels, microsurgical defect reconstruction of the trunk can be achieved by combining free flaps with arteriovenous loops. Here we present our 5-year experience of trunk reconstruction using AV loops and free flaps in a retrospective evaluation. We analyzed 32 cases of trunk reconstruction using a combined approach of free flap transplantation and arteriovenous loops between 2011 and 2016 regarding postoperative complications and perioperative course. Twenty-one patients suffered from sternal defects, 4 from presacral defects, 3 patients presented with lateral chest wall defects, 2 patients suffered from lumbosacral defects, 1 patient had a gluteal defect and 1 patient a defect at the clavicle. In all cases, free flap transplantation and arteriovenous loop creation were performed in a two-stage procedure. There were 8 thromboses of the arteriovenous loops with 4 flap failures. Only 1 flap loss was located in the sternal region, whereas one presacral flap and both lumbosacral flaps were lost. Reconstruction of large soft tissue defects of the trunk by a combined approach with an arteriovenous loop creation and consecutive free flap transplantation represents a reliable procedure in ventral and posterior cranial localization, whereas in the caudal posterior region, AV loop thrombosis can occur. Therefore, to minimize flap loss, a twostage procedure should be performed. Keywords:
Arteriovenous
loop;
Free
Flap
Transplantation;
Microsurgical
Transplantation; Trunk Reconstruction
3 Page 3 of 26
Introduction: Microsurgical transplantation of free flaps represents a safe and reliable technique for defect reconstruction even in large defects
1-3
. The microsurgical anastomosis of the
donor vessels at the recipient site requires adequate recipient vessels to ensure postoperative flap survival. In some cases, recipient vessels are missing or inadequate. In these situations free flap transplantation can still be achieved by means of arteriovenous loops (AV loops) using autologous vein grafts 4. In extremity revascularization, AV loop creation and subsequent free flap transfer represents one possible technique for limb salvage besides bypass or inflow reconstruction
5
.
Multiple studies have been published regarding these kinds of defect coverages in the extremities
6-8
. Using a combined approach of AV loops and microsurgical free
flap transplantation, defects in the trunk area can also be reconstructed. Although perforator based local flaps represent a possible defect reconstruction technique in selected cases in nearly every possible location 9, there are cases of complex tissue defects that require microsurgical free flap coverage
10
. Reasons for this can be the
size of the defect or inadequate perforators/recipient vessels due to compromised surrounding tissue. In this retrospective study we present our experiences with defect coverage using an AV loop and secondary microsurgical free flap transplantation in the trunk area with particular focus on AV loop patency and flap survival dependent on defect localization.
Materials and Methods: The study obtained ethical approval from the Ethical Committee of the University of Erlangen-Nürnberg (FAU) (reference number 160_17 Bc). Also, the authors adhered 4 Page 4 of 26
to the STROBE guidelines. Between January 2011 and July 2016, we performed defect coverage in the trunk region of 32 patients using arteriovenous loops and free flaps. The transplantation was always achieved in a two-stage procedure in an interdisciplinary approach. Firstly, the vascular surgeon created the arteriovenous loop, using an autologous great saphenous vein graft of the thigh anastomosed to a main arterial and venous vascular axis in an end-to-side fashion. Afterwards, flap transplantation was carried out in a secondary procedure. The reconstructions were reviewed regarding choice of flap, anastomosed main vascular axis for AV loop creation, defect entity and early postoperative complications. Patency of the AV loop and flap survival in the early postoperative course with regard to the defect localization were the main outcome variables of the study. Defect localization on the trunk was divided into ventral and posterior defects, with both groups being subdivided into cranial and caudal.
Results: The mean age of the patients was 57 years (ranging from 31 – 87 years), with 18 male and 14 female patients (Figure 1). The mean operation time for the flap transplantation was 293 min. (± 99 min.). 21 of 32 defects were located in the sternal region, one at the clavicle (all 22 classified as ventral cranial), 4 of the 7 dorsal caudal defects were located presacral (cavities ventral of the os sacrum), 2 lumbosacral and 1 gluteal. Three patients also suffered from lateral chest wall defects (Figure 2). Twenty-one AV loops were anastomosed in an end-to-side fashion to the subclavian vascular axis, 7 to the femoral vessels and 4 to the axillary vessels. There were 8 AV 5 Page 5 of 26
loop thromboses detectable, 4 occurred in the AV loops anastomosed to the femoral vessels, only 2 in the AV loops anastomosed to the subclavian vessels and 1 anastomosed to the axillary vessels (Figure 3). One AV loop was created between the cephalic vein and the common carotid artery. This AV loop was subsequently thrombosed and no flap transplantation was performed. In all cases, free flap transplantation and arteriovenous loop creation were performed in a two-stage procedure with AV loop creation in the first operation and consecutive free flap transplantation. The mean interval between these two operations was 9.5 days with the shortest interval of 2 days and the longest of 21 days (Figure 4). In 11 cases a myocutaneous vastus lateralis flap was transplanted, all for coverage of sternal defects (Figure 5). Twelve patients received a latissimus dorsi flap, one of them as a muscle sparing flap and one as a combined latissimus dorsi/parascapular flap. Seven patients were treated with a vertical rectus abdominis myocutaneous (VRAM) flap. Of the 22 patients with cranioventral defects, the majority (20 patients) presented with sternal defects resulting from sternal osteomyelitis, 1 patient was diagnosed with a metastasis of a cervix carcinoma, located at the anterior chest wall, and 1 patient presented with a defect at the cranial chest wall because of a pseudarthrosis of the clavicle (Figure 6). One patient died between AV loop creation and flap transplantation due to worsening of his overall cardiac condition. All lateral chest wall defects were covered using a previously created axillary arteriovenous loop and contralateral latissimus dorsi flap transplantation (Figure 7). The lateral chest wall defects were caused by a metastasis of an esophageal carcinoma, a metastasis of a thymic carcinoma and a fistula after multiple operations
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of a gastrointestinal stromal tumor. One patient suffered from a postoperative fistula which had to be revised operatively. Three patients with the presacral defects were treated because of rectal carcinomas, one patient had a sigmoid carcinoma (Figure 8). These four patients suffered of multiple abdominal operations previously combined with irradiation and chemotherapy. For presacral reconstruction femoral arteriovenous loops were created with consecutive free flap transfer. In one case the femoral arteriovenous loop had a venous thrombosis after free flap transplantation leading to flap loss. The one patient with the gluteal defect presented with a desmoid tumor recurrence. In this case two femoral arteriovenous loops were created but, due to postoperative loop thrombosis, defect coverage was finally achieved using two local flaps (S-GAP perforator flap and rotational flap) (Figure 9). One of the patients with a lumbosacral defect was diagnosed with a metastasis of a rectal carcinoma, the other patient suffered from a wound healing disorder after spinal stenosis surgery. Both AV loops created for defect coverage of the two lumbosacral defects (one to the axillary vessels with an intraoperative lengthening of the AV loop using another saphenous graft and one to the femoral vessels) showed postoperative thromboses, leading to consecutive flap losses. There was a total of four flap losses after secondary flap transplantation. There were four resections of the flap skin paddles due to inadequate vascularization and three tip necrosis of the flaps.
Discussion:
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Complex tissue defects in the trunk area are challenging for every reconstructive surgeon. Although some defects can be covered using perforator or other local flaps, sometimes free flap transfer is required. Arteriovenous loops can allow microsurgical free flap transplantation in areas without suitable recipient vessels 4. Main vascular axes in the trunk area for anastomosing the AV loop are the femoral vessels, subclavian vessels and axillary vessels. We have already published our experiences with AV loops and free tissue transfer in sternal wounds
11
and limb ischemia
6
as
well as our general experience with AV loops and free flaps independent of the area of reconstruction
12
. In this retrospective study, we focus on defects in the trunk
region. In our experience patency of the arteriovenous loops strongly correlates with the localization of the defect. Defects located on the ventral side, e.g. for sternal reconstructions usually require an AV loop anastomosed to the subclavian vessels. In our experience this kind of AV loop shows high patency rates, since only 2 of 21 AV loops (9.5%) were thrombosed, leading to 1 flap loss (4.8%). In previous studies in our department, there were no AV thromboses detectable in sternal AV loops
11
.
Reichenberger et al. described the so-called CTA loop, using the cephalic vein anastomosed to the thoracoacromial artery for sternal reconstructions
13
. In our
experience with the CTA loop from previous studies, we had much higher complication rates compared to the subclavian AV loop. In one case of this study, we anastomosed the cephalic vein to the common carotid artery, this AV loop was also thrombosed. Dornseifer et al. reported the use of the gastroepiploic vessels as recipient vessels for free flap transplantation to avoid AV loop creation
14
. In our
opinion, AV loop creation is a fast and less invasive procedure compared to
8 Page 8 of 26
harvesting the gastroepiploic vessels and hereby transforming a one-cavity procedure into a two-cavity procedure with an increased perioperative mortality. We also performed defect reconstruction in the cranial posterior trunk and the lateral chest wall using arteriovenous loops in cases, where pedicled flaps were not an option and recipient vessels were lacking. In this study we successfully treated three patients suffering from lateral chest wall due to tumor metastasis or fistula. All AV loops anastomosed to the axillary vessels were patent without any vascular complications. Gazyakan et al. reported of a bilateral chest wall reconstruction using ALT and TFL flaps anastomosed to an arteriovenous loop based on the axillary vessels 15. Tukiainen et al. were also able to reconstruct chest wall defects using TFL flaps combined with arteriovenous loops anastomosed to the femoral artery
16
.
In our experience, the most challenging defect area proved to be the posterior caudal trunk region. Five of eight arteriovenous loops showed thromboses (62.5%) leading to three flap losses. It is worth mentioning that only the two-stage procedure prevented us from more flap failures, so not every AV loop thrombosis led to a flap loss. Despite revision of the AV loop, none of these flaps was salvaged in these cases. Seven AV loops were anastomosed to the femoral vessels, whereas one AV loop was created using long interposed saphenous vein grafts to the axillary vessels. The technique of using arteriovenous loops in combination with free flap transplantation to reconstruct defects in the lumbosacral localization was first described by Salibian et al. in 1983
17
. In 1986, Nahai et al. first described the same
operation as a complete one-stage procedure
18
. In our case, we chose the axillary
vessels as the main vascular supply for the AV loop to have the opportunity to perform a two-stage procedure. This caused longer saphenous grafts, accompanied by the risk of impaired flow characteristics, possibly leading to 9 Page 9 of 26
stasis and thrombosis. There were also other authors who described defect coverage of lumbosacral defects by a latissimus dorsi flap, by lengthening the vascular pedicle using vein grafts
19, 20
. Four of the seven AV loops anastomosed to
the femoral vessels showed thromboses postoperatively, leading to two flap losses. The AV loops were created in order to reconstruct presacral or gluteal defects. Earle described this procedure in 1990 for gluteal, sacral and posterior thigh defects
21
.
They had no AV loop thromboses in both presented cases, whereas in our experience this kind of AV loop has a high potential for pedicle thromboses. For presacral defects, the AV loop was placed in the medial thigh, whereas for gluteal reconstructions the AV loop was guided laterally along and superior to the iliac crest. In both positions, we detected AV loop thromboses, although the venous distal end of the saphenous graft was reanastomosed to the femoral vein to prevent kinking of the venous pedicle instead of leaving it orthotopically in situ. So whenever possible, we would recommend local flaps such as rotational or perforator flaps in the gluteal/presacral region. We always use a workhorse flap with a low flow resistance in combination with AV loops, because perforator flaps or flaps with a high flow resistance (such as the gracilis muscle flap) often showed pedicle thromboses in the past when combined with a high-flow AV loop. Others report on AV loops combined with perforator flaps such as ALTs or AMTs
20
. One patient received defect coverage using local flaps (S-
GAP, rotational flap) due to repetitive AV loop thromboses. However, in this young female patient, the two pedicled flaps used as a “salvage procedure” would not have been the first choice, due to the significant disfiguring caused in particular by the large rotational flap. On the other hand, the scars of the free flap and vein harvest would also be difficult to hide. 10 Page 10 of 26
We always chose a two-stage procedure with AV loop creation in the first operation and consecutive free flap transplantation after some days, as it increases the safety of the entire procedure in our opinion. We prefer an interval between one and two weeks to ensure patency of the AV loop. In our experience, intervals longer than two weeks lead to an increased fibrosis of the AV loop vessel walls, possibly due to the arterialization of the venous graft. This process renders venous anastomosis using a coupler device impossible, while on the other hand no further increase in patency safety will be achieved after more than two weeks. In this study there could have been up to four more flap failures due to AV loop thromboses when transplanted in a one-stage procedure. So, from our point of view, the additional operating time is justified by the increase in flap procedure safety.
Conclusions: Large defects located in the trunk region are challenging, especially when local flaps are not available to reconstruct the defect and recipient vessels for free flap transplantation are missing or inadequate. In these cases, creation of an arteriovenous loop can allow microsurgical free flap transfer to cover the defect. This procedure represents a reliable technique to reconstruct ventral and cranial posterior defects of the trunk in particular, whereas the caudal posterior area remains difficult due to increased AV loop thromboses. In this region, local flaps such as rotational or perforator flaps are the best option whenever possible.
Conflict of interest statement: None declared. 11 Page 11 of 26
Acknowledgements: Proof reading of the article was performed by “proofreading.de”. This study did not receive any specific grant from funding agencies in the public, commercial, or not-forprofit sectors.
References: 1. Ludolph I, Apel H, Horch RE, Beier JP. Treatment of a chronic vesicocutaneous fistula and abdominal wall defect after resection of a soft tissue sarcoma using a bipedicled latissimus dorsi and serratus anterior free flap. International journal of urology : official journal of the Japanese Urological Association. 2014;21:1178-80. 2. Boos AM, Beckmann MW, Horch RE, Beier JP. Interdisciplinary Treatment for Cutaneous Abdominal Wall Metastasis from Cervical Cancer with Resection and Reconstruction of the Abdominal Wall Using Free Latissimus Dorsi Muscle Flap: A Case Report. Geburtshilfe und Frauenheilkunde. 2014;74:574-8. 3. Beier JP, Horch RE, Kneser U. Bilateral pre-expanded free TFL flaps for reconstruction of severe thoracic scar contractures in an 8-year-old girl. Journal of plastic, reconstructive & aesthetic surgery : JPRAS. 2013;66:1766-9. 4. Taeger CD, Arkudas A, Beier JP, Horch RE. Emergency arterio-venous loop for free-flap defect reconstruction of the lower thigh with a post-irradiated and heavily infected wound. International wound journal. 2015;12:598-600. 5. Horch RE, Lang W, Arkudas A, Taeger C, Kneser U, Schmitz M, et al. Nutrient free flaps with vascular bypasses for extremity salvage in patients with chronic limb ischemia. The Journal of cardiovascular surgery. 2014;55:265-72. 12 Page 12 of 26
6. Meyer A, Goller K, Horch RE, Beier JP, Taeger CD, Arkudas A, et al. Results of combined vascular reconstruction and free flap transfer for limb salvage in patients with critical limb ischemia. Journal of vascular surgery. 2015;61:1239-48. 7. Cavadas PC. Arteriovenous vascular loops in free flap reconstruction of the extremities. Plastic and reconstructive surgery. 2008;121:514-20. 8. Sunar H, Aygit CA, Afsar Y, Halici U, Duran E. Arterial and venous reconstruction for free tissue transfer in diabetic ischemic foot ulcers. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2004;27:210-5. 9. Kneser U, Beier JP, Schmitz M, Arkudas A, Dragu A, Schmidt VJ, et al. Zonal perfusion patterns in pedicled free-style perforator flaps. Journal of plastic, reconstructive & aesthetic surgery : JPRAS. 2014;67:e9-17. 10. Allen RJ, Jr., Lee ZH, Mayo JL, Levine J, Ahn C, Allen RJ, Sr. The Profunda Artery Perforator (PAP) Flap Experience for Breast Reconstruction. Plastic and reconstructive surgery. 2016. 11. Taeger CD, Horch RE, Arkudas A, Schmitz M, Stubinger A, Lang W, et al. Combined free flaps with arteriovenous loops for reconstruction of extensive thoracic defects after sternal osteomyelitis. Microsurgery. 2016;36:121-7. 12. Meyer A, Horch RE, Schoengart E, Beier JP, Taeger CD, Arkudas A, et al. Results of combined vascular reconstruction by means of AV loops and free flap transfer in patients with soft tissue defects. Journal of plastic, reconstructive & aesthetic surgery : JPRAS. 2016;69:545-53. 13. Reichenberger MA, Harenberg PS, Pelzer M, Gazyakan E, Ryssel H, Germann G, et al. Arteriovenous loops in microsurgical free tissue transfer in reconstruction of central sternal defects. The Journal of thoracic and cardiovascular surgery. 2010;140:1283-7. 13 Page 13 of 26
14. Dornseifer U, Kleeberger C, Ehrl D, Herter F, Ninkovic M, Iesalnieks I. Arteriovenous Loop-Independent Free Flap Reconstruction of Sternal Defects after Cardiac Surgery. Journal of reconstructive microsurgery. 2016;32:506-12. 15. Gazyakan E, Engel H, Lehnhardt M, Pelzer M. Bilateral double free-flaps for reconstruction of extensive chest wall defect. The Annals of thoracic surgery. 2012;93:1289-91. 16. Tukiainen E, Leppaniemi A. Reconstruction of extensive abdominal wall defects with microvascular tensor fasciae latae flap. The British journal of surgery. 2011;98:880-4. 17. Salibian AH, Tesoro VR, Wood DL. Staged transfer of a free microvascular latissimus dorsi myocutaneous flap using saphenous vein grafts. Plastic and reconstructive surgery. 1983;71:543-7. 18. Nahai F, Hagerty R. One-stage microvascular transfer of a latissimus flap to the sacrum using vein grafts. Plastic and reconstructive surgery. 1986;77:312-5. 19. Di Benedetto G, Bertani A, Pallua N. The free latissimus dorsi flap revisited: a primary option for coverage of wide recurrent lumbosacral defects. Plastic and reconstructive surgery. 2002;109:1960-5. 20. Harry BL, Deleyiannis FW. Posterior trunk reconstruction using an anteromedial thigh free flap and arteriovenous loop. Microsurgery. 2013;33:416-7. 21. Earle AS, Feng LJ, Jordan RB. Long saphenous vein grafts as an aid to microsurgical reconstruction of the trunk. Journal of reconstructive microsurgery. 1990;6:165-9.
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Figure Legends: Figure 1 Demographic data
Figure 2 22 defects were located ventral cranial, divided into 21 sternal defects and 1 defect in at the clavicle. There were 3 defects at the lateral chest wall and 7 defects in the posterior caudal region (4 presacral, 2 lumbosacral, 1 gluteal).
Figure 3 Total number of AV loops and thrombosed AV loops
Figure 4 AV loop and flap data
Figure 5 Number of flaps regarding flap type.
Figure 6
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76-year-old patient suffering from sternal osteomyelitis. After radical debridement (A) an AV loop was created to the subclavian vessels. Defect reconstruction was performed using a myocutaneous vastus lateralis flap (B) anastomosed to the AV loop limbs (C, arrow). D) Arterial (x) and venous (*) anastomoses of the lateral circumflex flap vessels to the AV loop. E) Result 7.5 months postoperatively.
Figure 7 52-year-old patient with a metastasis of an esophageal carcinoma (A). Intraoperative view demonstrating the lateral chest wall defect with exposed Gore-Tex® patch (arrow) after resection (B). An arteriovenous loop (*) was created to the axillary vessels (C) following defect reconstruction using a contralateral latissimus dorsi flap. D) Clinical result 1 month postoperatively.
Figure 8 62-year-old patient with a cavity ventral of the os sacrum due to a resection of a rectal carcinoma (arrow) (A). An arteriovenous loop was placed in the medial thigh and anastomosed to the femoral vessels (B). Postoperative MR angiography displayed a patent AV loop (C). Defect coverage of the cavity was achieved using a latissimus dorsi flap anastomosed to the AV loop (D).
Figure 9
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47-year-old patient with a recurrence of a gluteal desmoid tumor. A) defect after tumor resection. B) gluteal perforators of left S-GAP flap. C) Postoperative result after defect reconstruction using S-GAP and rotational flap. D) Postoperative result after 1 year.
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