MICROSURGERY
A Secure Technique for Microvascular Anastomosis in Arteries with Intimal Dissection Intimal Sleeve Fold-Over Technique Tung-Ying Hsieh, MD,* Yu-Hao Huang, MD,* Feng-Shu Chang, MD,* Chih-Hau Chang, MD,* Ko-Kang Chen, MD,* Shu-Hung Huang, MD,*† Chung-Sheng Lai, MD, PhD,*† Sin-Daw Lin, MD,*† and Kao-Ping Chang, MD, PhD*† Background: Intimal dissection can cause an irregular internal surface with intimal flaps and subendothelial collagen exposure. This has been associated with a high risk of thrombosis. Trimming the artery to a healthy level is routinely recommended to avoid intimal dissection. However, this method is limited when there is inadequate vascular length to work with. Methods: We dealt with an artery exhibiting severe intimal dissection by using a new suture technique: the intimal sleeve fold-over technique. Severe arterial intimal dissections were observed in 9 (6.9%) of 130 arterial microvascular anastomoses in free flap reconstruction for oral cancer patients from January 2013 to December 2013. We used this technique in 6 of the 9 patients. Results: All 6 patients were discharged as scheduled without perioperative problems and complications during follow-ups. The mean diameters of the recipient and pedicle arteries with intimal dissection were 2.13 and 2.20 mm. The mean time for performing sleeve fold-over procedure of on each artery was 5.1 minutes. Conclusions: A secure intima-to-intima contact can be achieved using this technique. This technique can provide an alternative method to intimal dissection when the length of the artery is limited. Key Words: intimal sleeve fold-over, intimal dissection, microvascular anastomosis, microsurgery (Ann Plast Surg 2016;76: 420–423)
I
ntimal dissection is a widespread problem encountered in microsurgery that poses a considerable challenge to microsurgeons. The etiology and incidence of intimal dissection were seldom mentioned in previous microsurgery journals. As Lin et al1 reported, 28.6% patients received living donor liver transplantation had intimal dissection in the recipient hepatic artery, and 57.5% of the patients underwent transarterial embolization for hepatocellular carcinoma before discovering the presence of intimal dissection. Intimal dissection of recipient hepatic artery encountered in liver transplantation may lead to life-threatening consequences. Meanwhile, in free flap reconstruction of head and neck defects, intimal dissection was also a critical and common problem. However, the incidence and the solution in head and neck reconstruction were rarely published.
Received June 9, 2014, and accepted for publication, after revision, October 6, 2014. From the *Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital; and †Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. Conflicts of interest and sources of funding: none declared. Reprints: Kao-Ping Chang MD, PhD, Division of Plastic and Reconstructive Surgery, Kaohsiung Medical University Hospital, 100 Shih-Chuan 1st Rd, Kaohsiung 807, Taiwan. E-mail: [email protected]. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.annalsplasticsurgery.com). Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7604–0420 DOI: 10.1097/SAP.0000000000000384
420
www.annalsplasticsurgery.com
Intimal dissection is characterized by a separation of the intima and media layers in the vascular tissue. This formation of irregular lumen surface results in turbulent blood flow and the exposure of the subendothelium causes platelet aggregation and thrombus formation.2 When intimal dissection is not managed carefully, the patency of the anastomosis remains problematic.3–5 Thus, the proposed technique used to avoid separating the intima from the media is crucial to favorable microvascular anastomosis. Several approaches have been proposed to deal with intimal dissection. Initial intervention is typically performed to trim the vessel until the intima is suitable for secure anastomosis, followed by the suture method in which a needle is passed through the lumen first (inside-out) to avoid further intima injury.3–5 However, these methods are restricted when the vascular length is limited before ideal vascular lumen is found.
PATIENTS AND METHODS One hundred thirty free flaps for reconstructing oral cancer patients who received wide excisions and neck dissections were performed in our institution from January 2013 to December 2013. Severe arterial intimal dissections were observed in 9 of 130 patients. Of the 9 patients, 2 of them have intact arteries with adequate length for anastomoses after trimming back. In 1 of the 9 patients, we had to use the alternative recipient artery. We approached these arteries by using the new suture technique, the intimal sleeve fold-over technique in 6 of the 9 patients. As Table 1 showed, 6 anastomoses between the superior thyroid artery and pedicles of the anterolateral thigh (ALT)/ radial forearm flaps were performed. In 4 of the 6 anastomoses, the suture technique was applied unilaterally on the recipient arteries (intimal dissection in the superior thyroid artery). In 2 of the 6 anastomoses, the suture technique was applied bilaterally on both ends (intimal dissection in both recipient and pedicle arteries). The step-by-step procedures are described as follows (see Video, Supplemental Digital Content 1, http://links.lww.com/SAP/A121): Step 1: Circumferential excision of the media layer (Figs. 1A and 2A)
We removed a small end portion of the media layer circumferentially to expose the intima. The length of media being removed is about one third to one half of the arterial diameter. The goal was to fold the intima layer inside out; thus, we sufficiently trimmed the media layer circumferentially. This was easily accomplished without injuring the intima because the dissection of the media and intima layers was clearly discernible. Step 2: Fold-over intimal sleeve (Figs. 1B and 2B)
We simply folded the intima over the media, similar to folding over a shirt sleeve. This allowed the 2 layers of tissue to remain in close contact. Annals of Plastic Surgery • Volume 76, Number 4, April 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
© 2014 Wolters Kluwer Health, Inc. All rights reserved.
69
54
69
50
55
49
Male
Male
Male
Male
Male
Male
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Buccal cancer
Buccal cancer
Buccal cancer
Buccal cancer
Buccal cancer
Buccal cancer
Diagnosis
Free ALT flap
Free radial forearm flap
Free ALT flap
Free ALT flap
Free ALT flap
Free ALT flap
Flap Type
Superior thyroid artery
Superior thyroid artery Superior thyroid artery Superior thyroid artery Superior thyroid artery Superior thyroid artery Pedicle of radial forearm flap Pedicle of ALT flap
Pedicle of ALT flap
Pedicle of ALT flap
Pedicle of ALT flap
Pedicle of ALT flap
Pedicle Artery
Superior thyroid artery
Superior thyroid artery Superior thyroid artery Superior thyroid artery Superior thyroid artery Superior thyroid artery
Recipient Artery
2.4†
—
Pedicle of radial forearm flap — 2.13†
1.8†
2.0†
2.2†
2.2†
2.2†
—
Pedicle of ALT flap —
Recipient Artery
2.20†
2.0
2.4†
2.2
2.0†
2.4
2.4
Pedicle Artery
Diameter
Pedicle Artery
Sleeve Fold-Over
*Complications include surgical reexploration, flap loss or partial necrosis, active bleeding, and wound infection. †Arteries with intimal dissection.
Average 57.7
Age, y
Sex
Recipient Artery
Anastomosis
TABLE 1. Patient Demographic, Anastomoses, and Results Data
5.1
4
3.5 (bilateral side, total 7 min)
5.5 (bilateral side, total 11 min) 3
4
7
Time for Sleeve Fold-Over Procedure of Each Side, min
Nil
Nil
Nil
Nil
Nil
Nil
Leakage
Patency
Patency
Patency
Patency
Patency
Patency
EmptyandRefill
Nil
Nil
Nil
Nil
Nil
Nil
Complication*
11.8
10
13
11
13
11
13
Hospitalization After Operation, d
Annals of Plastic Surgery • Volume 76, Number 4, April 2016 Intimal Sleeve Fold-Over Technique
www.annalsplasticsurgery.com
421
Annals of Plastic Surgery • Volume 76, Number 4, April 2016
Hsieh et al
have intact arteries with adequate length for anastomoses after trimming back. In 6 of the patients, the intimal sleeve fold-over technique was performed for successful anastomosis. We failed to perform the foldover technique on 1 patient due to severe atherosclerosis and friable intima. We use the alternative recipient artery for anastomosis. The applicability rate of this technique is 85.7% (6/7). Furthermore, the patency rate of the technique for intima dissection is 100% (6/6). Six patients using the intimal sleeve fold-over technique demographics and results are shown in Table 1. The mean diameters of recipient and pedicle arteries with intimal dissection were 2.13 and 2.20 mm. The mean time for performing sleeve fold-over procedure of each artery was 5.1 minutes. The intraoperative empty-and-refill tests also confirmed the patency of the anastomoses. Immediate leakage and dog-ears were not observed in any of the cases. The results of these 6 anastomoses were all successful without any complications thus far. The 6 patients were all discharged as scheduled (mean, 11.8 days).
DISCUSSION
FIGURE 1. A, Step 1: circumferential excision of the media layer. B and C, Step 2: fold-over intimal sleeve. D, Step 3: anastomosis.
Step 3: Anastomosis (Figs. 1D and 2D)
A normal vascular anatomy was obtained using the fold-over technique by tenting the undulating intima to the media. We performed microvascular anastomosis, similar to normal vascular anatomy, which produced minimal turbulence and anastomosis failure.
RESULTS Severe arterial intima dissections were observed in 9 of 130 patients. The principle in dealing with this problem is to trim back the blood vessel until intact artery is gained; thus, we approached the 9 patients by trimming back arteries first. Of the 9 patients, 2 of them 422
www.annalsplasticsurgery.com
The etiology of intimal dissection is uncertain. Some report that it is related to arterial trauma that could be accounted to vigorous grasping and traction during vascular dissection or arterial injury by previous intravascular procedure, such as transarterial embolization. To minimize this risk of intimal dissection, careful handling of the artery (no grasping or rough clamping of the vessels during the operation) and exclusively holding on to the adventitia layer delicately during vascular manipulation. The type of anastomosis, intima-to-intima contact, is highly similar to anastomosis using a coupler device. Histologic studies show the intima-to-intima contact area was well healed and reendothelialization wound be observed in 3 weeks.6 However, coupler devices are not designed for arterial intimal dissection and can cause intimal tearing and fragmentation.7 Chang et al8 reported that when the anastomotic artery wall is too thick, adequate eversion of the artery wall over the coupler device causes intimal injury or substantial reduction in intraluminal diameter. Thus, regardless of the size and thickness of the vascular wall in these cases, the secure intima-to-intima contact was easily accomplished using the intimal sleeve fold-over technique. As shown in Table 2, if the arterial length is adequate, traditional method (trimming of the artery to reach ideal intima conditions for anastomosis) and sleeve fold-over technique can both be used to manage intimal dissection. However, if the arterial length is insufficient, intimal dissection cannot be properly dealt with by traditional methods. Sleeve fold-over technique can be optimal in this situation. In addition, a coupler device is not designed for arterial intimal dissection. According to our experience (Table 1), it takes approximately 5.1 minutes for each sleeve fold-over procedure. A unilateral sleeve fold-over technique will take 5.1 minutes for one sleeve fold-over procedure and 15 minutes for the anastomosis procedure. On average, it takes 20.1 minutes to complete a unilateral sleeve fold-over technique and 25.2 minutes for bilateral sleeve fold-over altogether. Although arthrosclerosis is associated with a high risk of intimal dissection empirically, severe atherosclerosis is unsuitable for this technique. Folding the intima in a severely atherosclerotic vessel can induce intima fracture. Despite the advantages provided by using this technique, applying it to patients with severe atherosclerosis is not recommended if intima fracture is suspected. In conclusion, intimal dissection is correlated with a high risk of thrombosis attributable to irregular lumen, intimal flaps, and subendothelial collagen exposure. To overcome intimal dissection in microvascular anastomosis, we offered a simple replicable suture technique as a solution. A secure intima-to-intima contact was achieved using the intimal sleeve fold-over technique. This technique can serve as an alternative method in the situation of insufficient length of anastomotic artery with intimal dissection in head and neck surgery. © 2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 76, Number 4, April 2016
Intimal Sleeve Fold-Over Technique
FIGURE 2. A, Step 1: circumferential excision of the media layer. B, Step 2: fold-over intimal sleeve. Arrow, Intimal sleeve. C, Normal vascular anatomy is obtained using this fold-over technique. D, Step 3: anastomosis. The suture technique was applied bilaterally on both ends (intimal dissection of both recipient and pedicle vessels).
TABLE 2. Comparison for 3 Microvascular Anastomotic Technique
Intimal dissection with adequate artery length Intimal dissection with limited artery length Average operation time
Sleeve Fold-Over
Traditional Hand-Sewn
Coupler Device
O O Unilateral sleeve fold-over: 20.1 min* Bilateral sleeve fold-over: 25.2 min*
O (with trimming to good quality part of artery) X 15 min†
X X 6.3 min‡
*It takes approximately 5.1 minutes for each sleeve fold-over procedure. Average operation time = 5.1 minutes (1, unilateral side or 2, bilateral side) + time for traditional hand-sewn. †Data collected from our institute. ‡Vein (Chang et al8).
Further study for the intimal sleeve fold-over technique to manage intimal dissection in the recipient hepatic artery in adult living donor liver transplantation and the animal experimentation are in progress.
REFERENCES 1. Lin TS, Chiang YC, Chen CL, et al. Intimal dissection of the hepatic artery following transarterial embolization for hepatocellular carcinoma: an intraoperative problem in adult living donor liver transplantation. Liver Transpl. 2009;15:1553–1556. 2. Johnson PC. Platelet-mediated thrombosis in microvascular surgery: new knowledge and strategies. Plast Reconstr Surg. 1990;86:359–367.
© 2014 Wolters Kluwer Health, Inc. All rights reserved.
3. Gurtner GC, Neligan PC. Plastic Surgery: Volume 1: Principles. Amsterdam, Netherlands: Elsevier Health Sciences; 2012. 4. Wei FC, Mardini S. Flaps and Reconstructive Surgery, 1e. Philadelphia, PA: Saunders; 2009; Har/Dvdr/P edition. 5. Thorne CH, Bartlett SP, Beasley RW, et al. Grabb and Smith's Plastic Surgery. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013. 6. Blair WF, Morecraft RJ, Steyers CM, et al. A microvascular anastomotic device: Part II. A histologic study in arteries and veins. Microsurgery. 1989;10:29–39. 7. Jandali S, Wu LC, Vega SJ, et al. 1000 consecutive venous anastomoses using the microvascular anastomotic coupler in breast reconstruction. Plast Reconstr Surg. 2010;125:792–798. 8. Chang KP, Lin SD, Lai CS. Clinical experience of a microvascular venous coupler device in free tissue transfers. Kaohsiung J Med Sci. 2007;23:566–572.
www.annalsplasticsurgery.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
423
A Secure Technique for Microvascular Anastomosis in Arteries with Intimal Dissection Intimal Sleeve Fold-Over Technique Tung-Ying Hsieh, MD,* Yu-Hao Huang, MD,* Feng-Shu Chang, MD,* Chih-Hau Chang, MD,* Ko-Kang Chen, MD,* Shu-Hung Huang, MD,*† Chung-Sheng Lai, MD, PhD,*† Sin-Daw Lin, MD,*† and Kao-Ping Chang, MD, PhD*† Background: Intimal dissection can cause an irregular internal surface with intimal flaps and subendothelial collagen exposure. This has been associated with a high risk of thrombosis. Trimming the artery to a healthy level is routinely recommended to avoid intimal dissection. However, this method is limited when there is inadequate vascular length to work with. Methods: We dealt with an artery exhibiting severe intimal dissection by using a new suture technique: the intimal sleeve fold-over technique. Severe arterial intimal dissections were observed in 9 (6.9%) of 130 arterial microvascular anastomoses in free flap reconstruction for oral cancer patients from January 2013 to December 2013. We used this technique in 6 of the 9 patients. Results: All 6 patients were discharged as scheduled without perioperative problems and complications during follow-ups. The mean diameters of the recipient and pedicle arteries with intimal dissection were 2.13 and 2.20 mm. The mean time for performing sleeve fold-over procedure of on each artery was 5.1 minutes. Conclusions: A secure intima-to-intima contact can be achieved using this technique. This technique can provide an alternative method to intimal dissection when the length of the artery is limited. Key Words: intimal sleeve fold-over, intimal dissection, microvascular anastomosis, microsurgery (Ann Plast Surg 2016;76: 420–423)
I
ntimal dissection is a widespread problem encountered in microsurgery that poses a considerable challenge to microsurgeons. The etiology and incidence of intimal dissection were seldom mentioned in previous microsurgery journals. As Lin et al1 reported, 28.6% patients received living donor liver transplantation had intimal dissection in the recipient hepatic artery, and 57.5% of the patients underwent transarterial embolization for hepatocellular carcinoma before discovering the presence of intimal dissection. Intimal dissection of recipient hepatic artery encountered in liver transplantation may lead to life-threatening consequences. Meanwhile, in free flap reconstruction of head and neck defects, intimal dissection was also a critical and common problem. However, the incidence and the solution in head and neck reconstruction were rarely published.
Received June 9, 2014, and accepted for publication, after revision, October 6, 2014. From the *Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital; and †Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. Conflicts of interest and sources of funding: none declared. Reprints: Kao-Ping Chang MD, PhD, Division of Plastic and Reconstructive Surgery, Kaohsiung Medical University Hospital, 100 Shih-Chuan 1st Rd, Kaohsiung 807, Taiwan. E-mail: [email protected]. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.annalsplasticsurgery.com). Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7604–0420 DOI: 10.1097/SAP.0000000000000384
420
www.annalsplasticsurgery.com
Intimal dissection is characterized by a separation of the intima and media layers in the vascular tissue. This formation of irregular lumen surface results in turbulent blood flow and the exposure of the subendothelium causes platelet aggregation and thrombus formation.2 When intimal dissection is not managed carefully, the patency of the anastomosis remains problematic.3–5 Thus, the proposed technique used to avoid separating the intima from the media is crucial to favorable microvascular anastomosis. Several approaches have been proposed to deal with intimal dissection. Initial intervention is typically performed to trim the vessel until the intima is suitable for secure anastomosis, followed by the suture method in which a needle is passed through the lumen first (inside-out) to avoid further intima injury.3–5 However, these methods are restricted when the vascular length is limited before ideal vascular lumen is found.
PATIENTS AND METHODS One hundred thirty free flaps for reconstructing oral cancer patients who received wide excisions and neck dissections were performed in our institution from January 2013 to December 2013. Severe arterial intimal dissections were observed in 9 of 130 patients. Of the 9 patients, 2 of them have intact arteries with adequate length for anastomoses after trimming back. In 1 of the 9 patients, we had to use the alternative recipient artery. We approached these arteries by using the new suture technique, the intimal sleeve fold-over technique in 6 of the 9 patients. As Table 1 showed, 6 anastomoses between the superior thyroid artery and pedicles of the anterolateral thigh (ALT)/ radial forearm flaps were performed. In 4 of the 6 anastomoses, the suture technique was applied unilaterally on the recipient arteries (intimal dissection in the superior thyroid artery). In 2 of the 6 anastomoses, the suture technique was applied bilaterally on both ends (intimal dissection in both recipient and pedicle arteries). The step-by-step procedures are described as follows (see Video, Supplemental Digital Content 1, http://links.lww.com/SAP/A121): Step 1: Circumferential excision of the media layer (Figs. 1A and 2A)
We removed a small end portion of the media layer circumferentially to expose the intima. The length of media being removed is about one third to one half of the arterial diameter. The goal was to fold the intima layer inside out; thus, we sufficiently trimmed the media layer circumferentially. This was easily accomplished without injuring the intima because the dissection of the media and intima layers was clearly discernible. Step 2: Fold-over intimal sleeve (Figs. 1B and 2B)
We simply folded the intima over the media, similar to folding over a shirt sleeve. This allowed the 2 layers of tissue to remain in close contact. Annals of Plastic Surgery • Volume 76, Number 4, April 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
© 2014 Wolters Kluwer Health, Inc. All rights reserved.
69
54
69
50
55
49
Male
Male
Male
Male
Male
Male
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Buccal cancer
Buccal cancer
Buccal cancer
Buccal cancer
Buccal cancer
Buccal cancer
Diagnosis
Free ALT flap
Free radial forearm flap
Free ALT flap
Free ALT flap
Free ALT flap
Free ALT flap
Flap Type
Superior thyroid artery
Superior thyroid artery Superior thyroid artery Superior thyroid artery Superior thyroid artery Superior thyroid artery Pedicle of radial forearm flap Pedicle of ALT flap
Pedicle of ALT flap
Pedicle of ALT flap
Pedicle of ALT flap
Pedicle of ALT flap
Pedicle Artery
Superior thyroid artery
Superior thyroid artery Superior thyroid artery Superior thyroid artery Superior thyroid artery Superior thyroid artery
Recipient Artery
2.4†
—
Pedicle of radial forearm flap — 2.13†
1.8†
2.0†
2.2†
2.2†
2.2†
—
Pedicle of ALT flap —
Recipient Artery
2.20†
2.0
2.4†
2.2
2.0†
2.4
2.4
Pedicle Artery
Diameter
Pedicle Artery
Sleeve Fold-Over
*Complications include surgical reexploration, flap loss or partial necrosis, active bleeding, and wound infection. †Arteries with intimal dissection.
Average 57.7
Age, y
Sex
Recipient Artery
Anastomosis
TABLE 1. Patient Demographic, Anastomoses, and Results Data
5.1
4
3.5 (bilateral side, total 7 min)
5.5 (bilateral side, total 11 min) 3
4
7
Time for Sleeve Fold-Over Procedure of Each Side, min
Nil
Nil
Nil
Nil
Nil
Nil
Leakage
Patency
Patency
Patency
Patency
Patency
Patency
EmptyandRefill
Nil
Nil
Nil
Nil
Nil
Nil
Complication*
11.8
10
13
11
13
11
13
Hospitalization After Operation, d
Annals of Plastic Surgery • Volume 76, Number 4, April 2016 Intimal Sleeve Fold-Over Technique
www.annalsplasticsurgery.com
421
Annals of Plastic Surgery • Volume 76, Number 4, April 2016
Hsieh et al
have intact arteries with adequate length for anastomoses after trimming back. In 6 of the patients, the intimal sleeve fold-over technique was performed for successful anastomosis. We failed to perform the foldover technique on 1 patient due to severe atherosclerosis and friable intima. We use the alternative recipient artery for anastomosis. The applicability rate of this technique is 85.7% (6/7). Furthermore, the patency rate of the technique for intima dissection is 100% (6/6). Six patients using the intimal sleeve fold-over technique demographics and results are shown in Table 1. The mean diameters of recipient and pedicle arteries with intimal dissection were 2.13 and 2.20 mm. The mean time for performing sleeve fold-over procedure of each artery was 5.1 minutes. The intraoperative empty-and-refill tests also confirmed the patency of the anastomoses. Immediate leakage and dog-ears were not observed in any of the cases. The results of these 6 anastomoses were all successful without any complications thus far. The 6 patients were all discharged as scheduled (mean, 11.8 days).
DISCUSSION
FIGURE 1. A, Step 1: circumferential excision of the media layer. B and C, Step 2: fold-over intimal sleeve. D, Step 3: anastomosis.
Step 3: Anastomosis (Figs. 1D and 2D)
A normal vascular anatomy was obtained using the fold-over technique by tenting the undulating intima to the media. We performed microvascular anastomosis, similar to normal vascular anatomy, which produced minimal turbulence and anastomosis failure.
RESULTS Severe arterial intima dissections were observed in 9 of 130 patients. The principle in dealing with this problem is to trim back the blood vessel until intact artery is gained; thus, we approached the 9 patients by trimming back arteries first. Of the 9 patients, 2 of them 422
www.annalsplasticsurgery.com
The etiology of intimal dissection is uncertain. Some report that it is related to arterial trauma that could be accounted to vigorous grasping and traction during vascular dissection or arterial injury by previous intravascular procedure, such as transarterial embolization. To minimize this risk of intimal dissection, careful handling of the artery (no grasping or rough clamping of the vessels during the operation) and exclusively holding on to the adventitia layer delicately during vascular manipulation. The type of anastomosis, intima-to-intima contact, is highly similar to anastomosis using a coupler device. Histologic studies show the intima-to-intima contact area was well healed and reendothelialization wound be observed in 3 weeks.6 However, coupler devices are not designed for arterial intimal dissection and can cause intimal tearing and fragmentation.7 Chang et al8 reported that when the anastomotic artery wall is too thick, adequate eversion of the artery wall over the coupler device causes intimal injury or substantial reduction in intraluminal diameter. Thus, regardless of the size and thickness of the vascular wall in these cases, the secure intima-to-intima contact was easily accomplished using the intimal sleeve fold-over technique. As shown in Table 2, if the arterial length is adequate, traditional method (trimming of the artery to reach ideal intima conditions for anastomosis) and sleeve fold-over technique can both be used to manage intimal dissection. However, if the arterial length is insufficient, intimal dissection cannot be properly dealt with by traditional methods. Sleeve fold-over technique can be optimal in this situation. In addition, a coupler device is not designed for arterial intimal dissection. According to our experience (Table 1), it takes approximately 5.1 minutes for each sleeve fold-over procedure. A unilateral sleeve fold-over technique will take 5.1 minutes for one sleeve fold-over procedure and 15 minutes for the anastomosis procedure. On average, it takes 20.1 minutes to complete a unilateral sleeve fold-over technique and 25.2 minutes for bilateral sleeve fold-over altogether. Although arthrosclerosis is associated with a high risk of intimal dissection empirically, severe atherosclerosis is unsuitable for this technique. Folding the intima in a severely atherosclerotic vessel can induce intima fracture. Despite the advantages provided by using this technique, applying it to patients with severe atherosclerosis is not recommended if intima fracture is suspected. In conclusion, intimal dissection is correlated with a high risk of thrombosis attributable to irregular lumen, intimal flaps, and subendothelial collagen exposure. To overcome intimal dissection in microvascular anastomosis, we offered a simple replicable suture technique as a solution. A secure intima-to-intima contact was achieved using the intimal sleeve fold-over technique. This technique can serve as an alternative method in the situation of insufficient length of anastomotic artery with intimal dissection in head and neck surgery. © 2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 76, Number 4, April 2016
Intimal Sleeve Fold-Over Technique
FIGURE 2. A, Step 1: circumferential excision of the media layer. B, Step 2: fold-over intimal sleeve. Arrow, Intimal sleeve. C, Normal vascular anatomy is obtained using this fold-over technique. D, Step 3: anastomosis. The suture technique was applied bilaterally on both ends (intimal dissection of both recipient and pedicle vessels).
TABLE 2. Comparison for 3 Microvascular Anastomotic Technique
Intimal dissection with adequate artery length Intimal dissection with limited artery length Average operation time
Sleeve Fold-Over
Traditional Hand-Sewn
Coupler Device
O O Unilateral sleeve fold-over: 20.1 min* Bilateral sleeve fold-over: 25.2 min*
O (with trimming to good quality part of artery) X 15 min†
X X 6.3 min‡
*It takes approximately 5.1 minutes for each sleeve fold-over procedure. Average operation time = 5.1 minutes (1, unilateral side or 2, bilateral side) + time for traditional hand-sewn. †Data collected from our institute. ‡Vein (Chang et al8).
Further study for the intimal sleeve fold-over technique to manage intimal dissection in the recipient hepatic artery in adult living donor liver transplantation and the animal experimentation are in progress.
REFERENCES 1. Lin TS, Chiang YC, Chen CL, et al. Intimal dissection of the hepatic artery following transarterial embolization for hepatocellular carcinoma: an intraoperative problem in adult living donor liver transplantation. Liver Transpl. 2009;15:1553–1556. 2. Johnson PC. Platelet-mediated thrombosis in microvascular surgery: new knowledge and strategies. Plast Reconstr Surg. 1990;86:359–367.
© 2014 Wolters Kluwer Health, Inc. All rights reserved.
3. Gurtner GC, Neligan PC. Plastic Surgery: Volume 1: Principles. Amsterdam, Netherlands: Elsevier Health Sciences; 2012. 4. Wei FC, Mardini S. Flaps and Reconstructive Surgery, 1e. Philadelphia, PA: Saunders; 2009; Har/Dvdr/P edition. 5. Thorne CH, Bartlett SP, Beasley RW, et al. Grabb and Smith's Plastic Surgery. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013. 6. Blair WF, Morecraft RJ, Steyers CM, et al. A microvascular anastomotic device: Part II. A histologic study in arteries and veins. Microsurgery. 1989;10:29–39. 7. Jandali S, Wu LC, Vega SJ, et al. 1000 consecutive venous anastomoses using the microvascular anastomotic coupler in breast reconstruction. Plast Reconstr Surg. 2010;125:792–798. 8. Chang KP, Lin SD, Lai CS. Clinical experience of a microvascular venous coupler device in free tissue transfers. Kaohsiung J Med Sci. 2007;23:566–572.
www.annalsplasticsurgery.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
423
