Mateusz Gładysz FESSH prep

FESSH prep Microsurgery Conventional reversed orientation for arterial defects, gap length and the choice between interposition grafts and arteriovenous loops, effect on digit survival in replantation and revascularisation, arterial gap bridging after crush or avulsion injury, planned versus unplanned grafts

Interpositional vein grafts in microsurgery

Last reviewed v1.0

FESSH-087Microsurgery●○○ basic

Regarding interpositional vein grafts in microsurgery:

  1. 1.A reversed autologous vein graft is the conventional conduit for reconstructing a segmental defect of a digital artery.

  2. 2.For vessel gaps longer than about 10 cm, a single interposition vein graft is generally preferred to an arteriovenous loop or a flow-through flap.

  3. 3.The need for an interpositional graft to repair the digital artery should not in itself be considered a contraindication to digital replantation or revascularisation.

  4. 4.An interposition vein graft can permit a tension-free arterial repair after resection of damaged vessel segments in a crush or avulsion injury of a digit.

  5. 5.Vein grafts planned as part of the primary reconstruction have been associated with better free flap outcomes than unplanned grafts.

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Question ID
FESSH-087
First published
Last reviewed
Version
v1.0
Answer key and explanations — open after answering

  1. 1. A reversed autologous vein graft is the conventional conduit for reconstructing a segmental defect of a digital artery.

    True

    Remy and colleagues describe reconstruction with a reversed autologous vein graft as the traditional treatment of a digital arterial defect, and studied forearm perforator arteries as a possible alternative donor. In a rabbit femoral artery model (1-mm vessels, 2-cm defects), a non-reversed vein graft whose valves had been disrupted with a valvulotome achieved patency similar to the standard reversed graft (96% against 87%).

    • Remy H, Locatelli F, Maertens A, Balaguer T, Baqué P, Bronsard N, et al.. Arterial grafts for proper palmar digital artery reconstruction: An anatomical study. Hand Surg Rehabil. 2021;40(1):69-74. PMID 33137466
    • Mordick TG, Romanowski L, Eaton C, Siemionow M. Microvascular application of the nonreversed vein graft. Plast Reconstr Surg. 1995;95(4):731-6. PMID 7892319

  2. 2. For vessel gaps longer than about 10 cm, a single interposition vein graft is generally preferred to an arteriovenous loop or a flow-through flap.

    False

    In a review of vein grafts in free flap reconstruction that includes the practice points of three reconstructive microsurgeons at high-volume centres, gaps of less than 10 cm may be bridged with an interposition or transposition vein graft, whereas for longer gaps arteriovenous loops, transposition arteriovenous loops or flow-through flaps should be considered. This is expert guidance rather than comparative evidence.

    • Langdell HC, Shammas RL, Atia A, Chang EI, Matros E, Phillips BT. Vein Grafts in Free Flap Reconstruction: Review of Indications and Institutional Pearls. Plast Reconstr Surg. 2022;149(3):742-749. PMID 35196696

  3. 3. The need for an interpositional graft to repair the digital artery should not in itself be considered a contraindication to digital replantation or revascularisation.

    True

    Lee and colleagues found identical survival with and without a graft in revascularisation (91.5% in both groups) and no significant difference in replantation (48.1% against 46.2%), and concluded that the need for an interpositional graft should not be considered a contraindication to revascularisation or replantation. A pooled analysis of 32 replantation studies likewise found no significant association between survival and vein grafting. In one large series of fingertip replantations, crude survival was lower when a vein graft was needed (80.8% against 93.1%), but avulsion and zone II level were the risk factors identified on regression.

    • Lee ZH, Klifto CS, Milone MT, Cohen JM, Daar DA, Anzai L, et al.. Survival after Digit Replantation and Revascularization Is Not Affected by the Use of Interpositional Grafts during Arterial Repair. Plast Reconstr Surg. 2019;143(3):551e-557e. PMID 30601326
    • Shaterian A, Rajaii R, Kanack M, Evans GRD, Leis A. Predictors of Digit Survival following Replantation: Quantitative Review and Meta-Analysis. J Hand Microsurg. 2018;10(2):66-73. PMID 30154618
    • Kwon YJ, Jung HS, Ahn BM, Lee JS, Park HJ, Ha YC. Survival rates and risk factors for failure using an interposition vein graft for fingertip amputations with segmental vessel defects. Microsurgery. 2020;40(4):447-451. PMID 31926042

  4. 4. An interposition vein graft can permit a tension-free arterial repair after resection of damaged vessel segments in a crush or avulsion injury of a digit.

    True

    Crush and avulsion injuries can damage a length of artery. Resection to healthy vessel ends may leave a gap, which a vein graft can bridge without stretching the arterial repair.

    • Hyza P, Vesely J, Drazan L, Stupka I, Ranno R, Castagnetti F. Primary vein grafting in treatment of ring avulsion injuries: a 5-year prospective study. Annals of plastic surgery. 2007;59(2):163-7. PMID 17667410
    • Molski M. Replantation of fingers and hands after avulsion and crush injuries. J Plast Reconstr Aesthet Surg. 2007;60(7):748-54. PMID 17467354
    • Chang MK, Lim JX, Sebastin SJ. Current trends in digital replantation-a narrative review. Annals of translational medicine. 2024;12(4):66. PMID 39118941

  5. 5. Vein grafts planned as part of the primary reconstruction have been associated with better free flap outcomes than unplanned grafts.

    True

    In a 20-year series of 122 vein grafts in 72 free flaps, grafts were more successful when planned, and when transpositions or arteriovenous loops rather than interpositions were used. A review of vein grafts in free flap reconstruction notes that whether vein grafts increase flap failure is debated, but that complications are highest with unplanned grafts, in lower-limb reconstruction and with a long interval between the stages of an arteriovenous loop.

    • Inbal A, Silva AK, Humphries LS, Teven CM, Gottlieb LJ. Bridging the Gap: A 20-Year Experience with Vein Grafts for Free Flap Reconstruction. The Odds for Success. Plast Reconstr Surg. 2018;142(3):786-794. PMID 29965906
    • Langdell HC, Shammas RL, Atia A, Chang EI, Matros E, Phillips BT. Vein Grafts in Free Flap Reconstruction: Review of Indications and Institutional Pearls. Plast Reconstr Surg. 2022;149(3):742-749. PMID 35196696