Jeong Seong-Ho, Namgoong Sik, Dhong Eun-Sang, Han Seung-Kyu
Department of Plastic Surgery, Korea University Guro Hospital, Seoul, South Korea.
Front Surg. 2022 Sep 28;9:985245. doi: 10.3389/fsurg.2022.985245. eCollection 2022.
The free anterolateral thigh perforator (ALTP) flap has been successfully adopted to reconstruct traumatic soft tissue defects in the lower extremities. However, the occurrence of deep vein thrombosis (DVT) in donor or recipient veins has been overlooked, and there has been no reliable guideline to manage it. Therefore, in this study, we review our cases where the ALTP flaps were transferred to traumatic lower limbs even though DVT was found in the pedicle or recipient veins. Furthermore, based on our experiences, we suggest an algorithmic approach for dealing with DVT.
This study included 108 patients who underwent lower extremity reconstruction using a free ALTP flap between January 2014 and January 2021. All medical records were reviewed, including preoperative assessment data, intraoperative findings, and postoperative complications. Notably, when DVT was found in both the donor and recipient veins, we thoroughly assessed operative findings, surgical solutions, and final outcomes.
Sixty-one of 108 (56.4%) patients underwent computed tomographic venography (CTV) preoperatively, revealing DVT in 11 of these 61 (18%) patients. Three of these 11 patients had iliofemoral DVT, and surgery was delayed more than two weeks after detection. The remaining eight patients had calf DVT and underwent free ALTP flap transfer as scheduled. Conversely, 47 of 108 (43.6%) patients did not undergo CTV, and an occult DVT was found in five of these 47 (10.6%) patients. In two of these five patients, free flap surgery was replaced with amputation and local flap coverage. In the remaining three patients and one patient with an occult DVT that was not found on CTV, the free ALTP flap transfer was carried out. In 15 patients with DVT, free ALTP flap transfer was performed using various alternative methods for venorrhaphy. Consequently, all flaps survived, with partial necrosis occurring in two patients.
If DVT-affected veins are appropriately managed, the free ALTP flap can be successfully transferred to the traumatic lower limb even when DVT occurs in donor or recipient veins. The author's algorithm can help surgeons overcome the insufficiency of veins for pedicle anastomosis due to DVT and avoid postoperative thromboembolic complications.
游离股前外侧穿支（ALTP）皮瓣已成功用于修复下肢创伤性软组织缺损。然而，供体或受体静脉中深静脉血栓形成（DVT）的发生一直被忽视，且尚无可靠的处理指南。因此，在本研究中，我们回顾了尽管在蒂部或受体静脉中发现了DVT，但仍将ALTP皮瓣转移至创伤性下肢的病例。此外，基于我们的经验，我们提出了一种处理DVT的算法方法。
本研究纳入了2014年1月至2021年1月期间接受游离ALTP皮瓣下肢重建的108例患者。回顾了所有病历，包括术前评估数据、术中发现和术后并发症。值得注意的是，当在供体和受体静脉中均发现DVT时，我们全面评估了手术发现、手术解决方案和最终结果。
108例患者中有61例（56.4%）术前接受了计算机断层静脉造影（CTV），其中11例（18%）发现DVT。这11例患者中有3例为髂股DVT，发现后手术推迟了两周以上。其余8例患者为小腿DVT，按计划接受了游离ALTP皮瓣转移。相反，108例患者中有47例（43.6%）未接受CTV检查，其中47例中有5例（10.6%）发现隐匿性DVT。在这5例患者中的2例中，游离皮瓣手术被截肢和局部皮瓣覆盖所取代。在其余3例患者以及1例CTV未发现隐匿性DVT的患者中，进行了游离ALTP皮瓣转移。在15例DVT患者中，采用了各种替代的静脉缝合方法进行游离ALTP皮瓣转移。结果，所有皮瓣均存活，2例患者出现部分坏死。
如果对受DVT影响的静脉进行适当处理，即使供体或受体静脉出现DVT，游离ALTP皮瓣也可成功转移至创伤性下肢。作者的算法可帮助外科医生克服因DVT导致的蒂部吻合静脉不足问题，并避免术后血栓栓塞并发症。
