Successful salvage of venous thrombosis of a free flap by creation of a venocutaneous fistula.

This report describes the creation of a venocutaneous fistula to salvage a free fibular osteocutaneous flap compromised by extensive venous thrombosis. This technique has previously been described for salvage of digital replants, but this is the first report of a venocutaneous fistula being used to salvage a free flap. A 21-year-old woman underwent a 9-cm resection of the distal left tibia for an aneurysmal bone cyst. A contralateral right fibular osteocutaneous free flap was used for reconstruction. On postoperative day 2, the skin paddle showed evidence of venous congestion. Reexploration demonstrated extensive thrombosis throughout the entire venous system of the flap. The venae comitantes were transected as far back as possible and brought to the surface of the skin through two small stab wounds to allow venous egress. After a short course of heparin and dextran, the skin flap healed uneventfully and both osteosynthesis sites consolidated. A venocutaneous fistula provides a path of relatively low resistance for venous outflow, improving the arterial inflow-venous outflow balance for a short time until neovascularization and collateral venous channels develop. The venocutaneous fistula technique may be considered for salvage of free flaps compromised by extensive venous thrombosis.