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Spontaneous arteriovenous shunt after microsurgical operation
Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 1569e1571
CASE REPORT
Spontaneous arteriovenous shunt after microsurgical operation Shan Zhu, Yuanbo Liu*, Bin Song, Donghong Liu Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Peking Union Medical College, Ba-Da-Chu road 33#, Beijing 100144, The People’s Republic of China Received 30 October 2009; accepted 7 February 2010
KEYWORDS Ateriovenous shunt; Flap; Microsurgery
Summary Arteriovenous fistulae are abnormal communications between arteries and veins, leading to bypass of the normal capillary bed circulation, often with progressive enlargement giving rise to multiple complications. The occurrence of the arteriovenous fistula after a microsurgical operation is a rare complication. Hurst and Sukop have reported the occurrence of arteriovenous fistulae following replantation surgery; Collin has reported an arteriovenous fistula arising in a free flap in head and neck surgery. There are no published accounts of the arteriovenous fistula arising in free flaps in hand surgery. In this article, we present the case report of a patient with a spontaneous arteriovenous fistula followed by free transfer of an anterolateral thigh flap, a rare complication in free flap surgery. ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Arteriovenous fistulae are abnormal communications between arteries and veins, leading to bypass of the normal capillary bed circulation, often with progressive enlargement giving rise to multiple complications. The occurrence of the arteriovenous fistula after a microsurgical operation is a rare complication. Hurst1 and Sukop2 have reported arteriovenous fistulae following replantation surgery; Collin3 has reported an arteriovenous fistula arising in a free flap in head and neck surgery. There are no published accounts of the arteriovenous fistula arising in free flaps in
* Corresponding author. Fax: þ010 88964137. E-mail address: [email protected] (Y. Liu).
hand surgery. In this article, we present the case report of a patient with a spontaneous arteriovenous fistula followed by free transfer of an anterolateral thigh flap, a rare complication in free flap surgery.
Case report A 46-year-old man sustained an electrical injury to his left hand and wrist in April 2008. Complete debridement of the wound demonstrated that the radial artery was intact and the ulnar artery was occlusive distal to the level of the wrist. An anterolateral thigh free flap was used to resurface the resultant defect. The lateral circumflex femoral artery was anastomosed end to end to the proximal portion of the
1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.02.019
1570 ulnar artery, and one concomitant vein was connected end to end to the cephalic vein. The flap survived completely after surgery. In March 2009 a bulge was found, in the distal portion of the forearm proximal to the flap, which exacerbated in time. The patient could feel the abnormal pulsation by himself and complained of swelling and numbness in his left hand. In September 2009 he was referred to our centre. Physical examination revealed a soft compressible swelling with an associated bruit and a palpable thrill. An exploratory operation was done and a well-developed arteriovenous shunt between the distal end of the ulnar artery and the cephalic vein was found. There were still two arterial branches from the ulnar artery with relative small calibre distributing to the flap. The arteriovenous fistula was resected and the distal end of the ulnar artery was ligated, preserving the integrity of the two arterial branches to the flap. After the surgery, the abnormal pulsation disappeared and swelling of the left hand was significantly improved (Figure 1).
Discussion The cause of arteriovenous fistulae may be congenital or acquired, and the latter is usually caused by an identifiable traumatic insult.4 The possible events of the trauma are often penetrating injury, blunt injury, infection and changes in local haemodynamics.3 The lesions have propensities for haemorrhage, ulceration and rapid enlargement after an attempted surgical excision, and the most severe cases can even develop cardiac failure and ‘steal phenomenon’ because of the massive shunting of blood through the fistula.3 It is important to distinguish the
S. Zhu et al. two different types of arteriovenous fistulae and manage them accordingly. Sukop et al.2 preferred selective ligation of the common digital artery to a late arteriovenous fistula after finger replantation. In the case presented, the patient suffered from an electrical injury over his left hand prior to surgery. An anterolateral thigh flap was harvested and used to resurface the resultant wound. Eleven months later, an arteriovenous shunt between the distal end of the ulnar artery and the cephalic vein was detected. Many preoperative evaluations, such as arteriography and angio-computerised tomography, were recommended to provide the best anatomical detail and structural information on the vascular disorders. However, due to the economic limitation of the patient and the recognition of clinically significant symptoms of an arteriovenous fistula, these invasive examinations were not performed. Because of the ineffective conservative therapy, surgical ligation and resection of the arteriovenous fistula were performed. Symptoms of swelling and numbness of the left hand of the patient were greatly improved after the surgery. As to the aetiology of the fistula, we hypothesise that, due to close contiguity of the vessels, a neogenetic vascular connection may have developed between the artery and vein in the flap pedicle. In time, when this connection matured, the altered haemodynamics ultimately induced the circulation through the arteriovenous shunt, which caused vasodilatation of the involved vessels. Experimental studies in animals and clinical reports have shown that partial, and even complete, survival of flap is possible after interrupting the vascular blood supply to the flap as early as 3e9 days postoperatively.5,6 Khoo observed
Figure 1 (A) Abnormal prominence can be seen proximal to the flap preoperatively. (B) A well-developed arteriovenous shunt has been dissected out. (C) Two branches from the ulnar artery distribute to proximal portion of the flap. (D) The final appearance after the surgery.
Spontaneous arteriovenous shunt that a large portion of a muscular, musculocutaneous or osseo-musculocutaneous free flap which has lost its axial blood supply would survive at an early stage.7 Sukop et al.2 reported that satisfactory results have been obtained using selective ligation of the dilated common digital artery of an arteriovenous malformation 6 months after finger replantation. In our experience, when a free flap is debulked as an adjunctive procedure 3 months after the initial surgery, the major feeding vessels can be safely ligated without compromise to the viability of the flap. Therefore, we would recommend resection of these arteriovenous shunts as the flap-pedicle vessels are of no significant use to the flap viability after a long period of time. Further experimental work is required to answer these relevant clinical issues.
Conflict of interest statement None of the authors has a financial interest to disclose in relation to the content of this article.
Funding statement There are no funding sources that need to be disclosed of this article.
1571
Ethics statement Our study conforms to the World Medical Association Declaration of Helsinki (June 1964) and subsequent amendments. The research protocol was approved by the Ethical Committee of Plastic Surgery Hospital of Peking Union Medical College, Beijing, China.
References 1. Hurst LN, Rankin RN, Antonyshyn OM. Arteriovenous fistulas after replantation surgery. Plast Reconstr Surg 1986;77:664e7. 2. Sukop A, Kufa R, Dusˇkova ´ M. Late arteriovenous fistula after finger replantation. Eur J Plast Surg 2006;28:421e5. 3. Collin TW, Morris P, Sassoon E, et al. Arteriovenous fistula in a free pectoralis minor flap. Eur J Plast Surg 2003;26:367e9. 4. Ninkovic ´ M, ˇSuc ´ur D, Starovic ´ B, et al. Arteriovenous fistulae after free flap surgery in a replanted hand. J Hand Surg [Br] 1992;17B:657e9. 5. Serafin D, Shearin JC. The vascularisation of free flaps: clinical and experimental correlation. Plast Reconstr Surg 1977;60: 233e41. 6. Rothaus KO, Acland RD. Free flap neo-vascularization: case report. Br J Plast Surg 1983;36:348e9. 7. Khoo CTK, Bailey BN. The behaviour of free muscle and musculocutaneous flaps after early loss of axial blood supply. Br J Plast Surg 1982;35:43e6.
CASE REPORT
Spontaneous arteriovenous shunt after microsurgical operation Shan Zhu, Yuanbo Liu*, Bin Song, Donghong Liu Department of Plastic and Reconstructive Surgery, Plastic Surgery Hospital, Peking Union Medical College, Ba-Da-Chu road 33#, Beijing 100144, The People’s Republic of China Received 30 October 2009; accepted 7 February 2010
KEYWORDS Ateriovenous shunt; Flap; Microsurgery
Summary Arteriovenous fistulae are abnormal communications between arteries and veins, leading to bypass of the normal capillary bed circulation, often with progressive enlargement giving rise to multiple complications. The occurrence of the arteriovenous fistula after a microsurgical operation is a rare complication. Hurst and Sukop have reported the occurrence of arteriovenous fistulae following replantation surgery; Collin has reported an arteriovenous fistula arising in a free flap in head and neck surgery. There are no published accounts of the arteriovenous fistula arising in free flaps in hand surgery. In this article, we present the case report of a patient with a spontaneous arteriovenous fistula followed by free transfer of an anterolateral thigh flap, a rare complication in free flap surgery. ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Arteriovenous fistulae are abnormal communications between arteries and veins, leading to bypass of the normal capillary bed circulation, often with progressive enlargement giving rise to multiple complications. The occurrence of the arteriovenous fistula after a microsurgical operation is a rare complication. Hurst1 and Sukop2 have reported arteriovenous fistulae following replantation surgery; Collin3 has reported an arteriovenous fistula arising in a free flap in head and neck surgery. There are no published accounts of the arteriovenous fistula arising in free flaps in
* Corresponding author. Fax: þ010 88964137. E-mail address: [email protected] (Y. Liu).
hand surgery. In this article, we present the case report of a patient with a spontaneous arteriovenous fistula followed by free transfer of an anterolateral thigh flap, a rare complication in free flap surgery.
Case report A 46-year-old man sustained an electrical injury to his left hand and wrist in April 2008. Complete debridement of the wound demonstrated that the radial artery was intact and the ulnar artery was occlusive distal to the level of the wrist. An anterolateral thigh free flap was used to resurface the resultant defect. The lateral circumflex femoral artery was anastomosed end to end to the proximal portion of the
1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.02.019
1570 ulnar artery, and one concomitant vein was connected end to end to the cephalic vein. The flap survived completely after surgery. In March 2009 a bulge was found, in the distal portion of the forearm proximal to the flap, which exacerbated in time. The patient could feel the abnormal pulsation by himself and complained of swelling and numbness in his left hand. In September 2009 he was referred to our centre. Physical examination revealed a soft compressible swelling with an associated bruit and a palpable thrill. An exploratory operation was done and a well-developed arteriovenous shunt between the distal end of the ulnar artery and the cephalic vein was found. There were still two arterial branches from the ulnar artery with relative small calibre distributing to the flap. The arteriovenous fistula was resected and the distal end of the ulnar artery was ligated, preserving the integrity of the two arterial branches to the flap. After the surgery, the abnormal pulsation disappeared and swelling of the left hand was significantly improved (Figure 1).
Discussion The cause of arteriovenous fistulae may be congenital or acquired, and the latter is usually caused by an identifiable traumatic insult.4 The possible events of the trauma are often penetrating injury, blunt injury, infection and changes in local haemodynamics.3 The lesions have propensities for haemorrhage, ulceration and rapid enlargement after an attempted surgical excision, and the most severe cases can even develop cardiac failure and ‘steal phenomenon’ because of the massive shunting of blood through the fistula.3 It is important to distinguish the
S. Zhu et al. two different types of arteriovenous fistulae and manage them accordingly. Sukop et al.2 preferred selective ligation of the common digital artery to a late arteriovenous fistula after finger replantation. In the case presented, the patient suffered from an electrical injury over his left hand prior to surgery. An anterolateral thigh flap was harvested and used to resurface the resultant wound. Eleven months later, an arteriovenous shunt between the distal end of the ulnar artery and the cephalic vein was detected. Many preoperative evaluations, such as arteriography and angio-computerised tomography, were recommended to provide the best anatomical detail and structural information on the vascular disorders. However, due to the economic limitation of the patient and the recognition of clinically significant symptoms of an arteriovenous fistula, these invasive examinations were not performed. Because of the ineffective conservative therapy, surgical ligation and resection of the arteriovenous fistula were performed. Symptoms of swelling and numbness of the left hand of the patient were greatly improved after the surgery. As to the aetiology of the fistula, we hypothesise that, due to close contiguity of the vessels, a neogenetic vascular connection may have developed between the artery and vein in the flap pedicle. In time, when this connection matured, the altered haemodynamics ultimately induced the circulation through the arteriovenous shunt, which caused vasodilatation of the involved vessels. Experimental studies in animals and clinical reports have shown that partial, and even complete, survival of flap is possible after interrupting the vascular blood supply to the flap as early as 3e9 days postoperatively.5,6 Khoo observed
Figure 1 (A) Abnormal prominence can be seen proximal to the flap preoperatively. (B) A well-developed arteriovenous shunt has been dissected out. (C) Two branches from the ulnar artery distribute to proximal portion of the flap. (D) The final appearance after the surgery.
Spontaneous arteriovenous shunt that a large portion of a muscular, musculocutaneous or osseo-musculocutaneous free flap which has lost its axial blood supply would survive at an early stage.7 Sukop et al.2 reported that satisfactory results have been obtained using selective ligation of the dilated common digital artery of an arteriovenous malformation 6 months after finger replantation. In our experience, when a free flap is debulked as an adjunctive procedure 3 months after the initial surgery, the major feeding vessels can be safely ligated without compromise to the viability of the flap. Therefore, we would recommend resection of these arteriovenous shunts as the flap-pedicle vessels are of no significant use to the flap viability after a long period of time. Further experimental work is required to answer these relevant clinical issues.
Conflict of interest statement None of the authors has a financial interest to disclose in relation to the content of this article.
Funding statement There are no funding sources that need to be disclosed of this article.
1571
Ethics statement Our study conforms to the World Medical Association Declaration of Helsinki (June 1964) and subsequent amendments. The research protocol was approved by the Ethical Committee of Plastic Surgery Hospital of Peking Union Medical College, Beijing, China.
References 1. Hurst LN, Rankin RN, Antonyshyn OM. Arteriovenous fistulas after replantation surgery. Plast Reconstr Surg 1986;77:664e7. 2. Sukop A, Kufa R, Dusˇkova ´ M. Late arteriovenous fistula after finger replantation. Eur J Plast Surg 2006;28:421e5. 3. Collin TW, Morris P, Sassoon E, et al. Arteriovenous fistula in a free pectoralis minor flap. Eur J Plast Surg 2003;26:367e9. 4. Ninkovic ´ M, ˇSuc ´ur D, Starovic ´ B, et al. Arteriovenous fistulae after free flap surgery in a replanted hand. J Hand Surg [Br] 1992;17B:657e9. 5. Serafin D, Shearin JC. The vascularisation of free flaps: clinical and experimental correlation. Plast Reconstr Surg 1977;60: 233e41. 6. Rothaus KO, Acland RD. Free flap neo-vascularization: case report. Br J Plast Surg 1983;36:348e9. 7. Khoo CTK, Bailey BN. The behaviour of free muscle and musculocutaneous flaps after early loss of axial blood supply. Br J Plast Surg 1982;35:43e6.