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Successful free flap transfer following venous thrombectomy in recipient vessel
524
British Journal of Plastic Surgery
BritishJournalofPlasticSurgery(2000),53,
9 2000The BritishAssociationof PlasticSurgeons DOI: 10.1054/bjps.2000.3385
Successful free flap transfer following venous thrombectomy in recipient vessel O. P. Shelley, S. B. Watson* and I. Taggart*
Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; and *West of Scotland Regional Plastic Surgery, Trauma and Burns Unit, Glasgow Royal Infirmary, Glasgow, Scotland, UK SUMMARY. We report the case of a 53-year-old male patient who suffered a high velocity multiple trauma with bilateral open tibial fractures. At definitive orthopaedic and plastic surgical reconstruction 5 days post initial trauma, he was found peroperatively to have an existing deep venous thrombosis in his popliteal vein on one side. He underwent venous thrombectomy and had subsequent successful latissimus dorsi flap transfer using the unblocked popliteal vein as a recipient vessel 9 2000 The British Association of Plastic Surgeons
Keywords: flap, thrombosis, thrombectomy, lower limb injury.
Case report We report the case of a 53-year-old male patient who was admitted following high velocity multiple trauma, with bilateral Gustillo IIIB open tibial and fibular fractures and a fracture of his right ulna. His initial management in the referring hospital consisted of resuscitation, placement of bilateral external fixators (Fig. 1) and plating of his ulnar fracture. Following his initial treatment he was transferred to our care, where he was found to have bilateral segmental tibial and fibular fractures with associated soft tissue defects measuring 20 • 30 cm on the
right lower leg, and 15 • 20cm on the left side directly overlying the fracture sites. A combined plastic surgical and orthopaedic procedure was planned, consisting of open reduction and internal fixation of his fractures and bilateral latissimus dorsi flaps for cover. Definitive bony fixation was achieved and the first flap transferred to the recipient site on the left leg, with end-to-side anastomoses performed successfully. On preparing the recipient vessels for the tatissimus dorsi transfer to the right leg, a thrombus was identified within the popliteal vein, a finding which would normally have precluded free tissue transfer. Options considered included amputation of the limb, venous reconstruction using vein grafts, thrombectomy or intravascular thrombolysis. 1As there were no local alternatives to give adequate soft tissue cover, a popliteal venous thrombectomy was performed 2 using a Fogarty balloon catheter, and a 7 cm thrombus was removed from the popliteal vein. The popliteal vein was then heparinised. After good flow was established, a venotomy was performed proximal to the embolectomy site and the latissimus dorsi flap was transferred, again with an end-to-side anastomosis of the thoracodorsal to the popliteal vessels. The patient made an uneventful recovery and both flaps remained welt perfused without need for re-exploration. The patient was systemically heparinised postoperatively, and subsequently warfarinised for 3 months. There has been no clinical or radiological evidence of further deep venous thrombosis, pulmonary embolism, or any symptoms or signs of venous hypertension in the limb in which thrombectomy was performed. Now 24 months postoperatively, the patient has stable bony union with good soft tissue cover and is fully ambulant.
Discussion
Figure 1--X-ray showing bilateral lower limb injury with segmental fractures of right tibia and fibularesultingin poplitealvein thrombosis. This paper was presented at the Scottish-Irishmeetingwhich took place in Livingstone,Scotlandin October 1998.
Deep venous thrombosis of the lower limbs is frequently seen in surgical services and is a well known complication of limb trauma, with evidence of clot formation as early as 6 h after trauma. 3'4 The incidence of venous thrombosis in the acute setting is not accurately known, but it has been shown to affect 69% of major trauma patients with lower extremity orthopaedic injuries, and 77% of patients with tibial fractures. 5 This increased incidence is likely to be related to a combination of direct vessel wall trauma, stasis and local tissue hypoxia. 3'4
Giant inguinoscrotal hernia repair
525 3. Thomas DE Pathogenesis of venous thrombosis. In: Bloom AL, Thomas DE eds. Haemostasis and Thrombosis. Edinburgh: Churchill Livingstone, 1987: 767-78. 4. Hirsh J, Weitz JI. Venous thromboembolism. In: Hoffman R, ed. Hematology: basic principles and practice. New York: Churchill Livingstone, 1990: 1829-42. 5. Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous thromboembolism after major trauma. N Engl J Med 1994; 331: 1601-6. 6. Godina M. Selection of Recipient Vessels in the Lower Leg for Microvascular Flap Transfer, Marko Godina a Thesis. Ljubljana: University of Ljubljana, 1991. 7. Benacquista T, Kasabian AK, Karp NS. The fate of lower extremities with failed free flaps. Plast Reconstr Surg 1996; 98: 834-42. 8. Fuchs JCA, Hagen PO. Long-term fate of autologous vein grafts. In: Serafin D, Buncke HJ Jr, Sabiston DC Jr, Powell DG, eds. Microsurgical Composite Tissue Transplantation. St. Louis: Mosby, 1979: 90-107. 9. Suominen S, Asko-Seljavaara S. Free flap failures. Microsurgery 1995; 16: 396-9.
No cases of successful free tissue transfer following thrombectomy in recipient vessels have previously been described. There are no guidelines for the management of a patient with established deep venous thrombosis at the time of free tissue transfer. Veins and arteries within the zone of injury are known to be less suitable recipient vessels. 6 Free flap failure in the context of lower limb trauma is c o m m o n and leads to a high amputation rate. 7 Autologous vein grafts are the best replacement of small vessels but distinct pathological changes occur which may affect graft function. 8 The exact rate of thrombosis is uncertain but has been estimated to be 42% in aorto-coronary bypass, and is felt to be higher when used in lower extremities. 5 The use of vein grafts also correlates with immediate vascular complications. 9 The use of anticoagulants following free flap transfer increases the complication rate to 50%. 7 The treatment options in a patient with an open fracture requiring free tissue transfer, whose only recipient vessel is thrombosed, are limited and a high risk of flap failure must be anticipated. We would like to present venous thrombectomy as a potential treatment option which proved successful on this occasion.
Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA.
References
Smart B. Watson FRCS(Plast) lan Taggart FRCS(Plast), Consultant Plastic Surgeon
1. Husni EA. Venous reconstructive procedures. In DeWeese JA, ed. Rob and Smith's Operative Surgery: vascular surgery. London: Butterworths, 1985: 334-41. 2. DeWeese JA. Venous thrombectomy.In DeWeese JA, ed. Rob and Smith's Operative Surgery: vascular surgery. London: Butterworths, 1985: 318-24.
The Authors Odhran P. Shelley FRCSI
West of Scotland Regional Plastic Surgery,Trauma and Burns Unit, Glasgow Royal Infirmary, Glasgow G4 0SF, UK. Correspondence to Mr Ian Taggart. Paper received 16 April 1999. Accepted 10 May 2000, after revision.
BritishJournalofPlasticSurgery(2000),53
9 2000The BritishAssociationof PlasticSurgeons DOI: 10.1054/bjps.2000.3383
Repair of a giant inguinoscrotal hernia E V. Mehendale, K. O. Taams and A. N. Kingsnorth*
Department of Plastic Surgery and *Department of General Surgery, Derriford Hospital, Plymouth, UK SUMMARY. We present a case of a long-standing, giant inguinoscrotal hernia extending to the patient's knees, complicated by intestinal obstruction. Initial management involved conservative treatment of the intestinal obstruction and optimising the patient's general condition. Surgical treatment included debulking the contents of the hernia sac by performing a right hemicolectomy and a small bowel resection, and reconstruction of the abdominal wall using Marlex mesh and a tensor fasciae latae flap. Although abdominal wall reconstruction for massive ventral or incisional herniae is well reported, inguinoscrotal herniae of this magnitude are much rarer and pose additional problems, which are discussed in this paper. 9 2000 The British Association of Plastic Surgeons K e y w o r d s : giant inguinoscrotal hernia, abdominal wall reconstruction, tensor fasciae latae flap.
Giant inguinoscrotal herniae have been defined as those that extend below the midpoint of the inner thigh in the standing position. 1 A number of reconstructive techniques have been reported for the treatment of massive ventral herniae, including tissue expansion, 2 'components separation'3 and preoperative pneumoperitoneum with or
without the use of synthetic mesh. 4,5 However, treatment of the considerably less common, giant inguinoscrotal hernia is less frequently reported. 1'6'7 Although there are similarities in the management o f both types of herniae, giant inguinoscrotal herniae present specific problems that are illustrated by this case report.
British Journal of Plastic Surgery
BritishJournalofPlasticSurgery(2000),53,
9 2000The BritishAssociationof PlasticSurgeons DOI: 10.1054/bjps.2000.3385
Successful free flap transfer following venous thrombectomy in recipient vessel O. P. Shelley, S. B. Watson* and I. Taggart*
Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; and *West of Scotland Regional Plastic Surgery, Trauma and Burns Unit, Glasgow Royal Infirmary, Glasgow, Scotland, UK SUMMARY. We report the case of a 53-year-old male patient who suffered a high velocity multiple trauma with bilateral open tibial fractures. At definitive orthopaedic and plastic surgical reconstruction 5 days post initial trauma, he was found peroperatively to have an existing deep venous thrombosis in his popliteal vein on one side. He underwent venous thrombectomy and had subsequent successful latissimus dorsi flap transfer using the unblocked popliteal vein as a recipient vessel 9 2000 The British Association of Plastic Surgeons
Keywords: flap, thrombosis, thrombectomy, lower limb injury.
Case report We report the case of a 53-year-old male patient who was admitted following high velocity multiple trauma, with bilateral Gustillo IIIB open tibial and fibular fractures and a fracture of his right ulna. His initial management in the referring hospital consisted of resuscitation, placement of bilateral external fixators (Fig. 1) and plating of his ulnar fracture. Following his initial treatment he was transferred to our care, where he was found to have bilateral segmental tibial and fibular fractures with associated soft tissue defects measuring 20 • 30 cm on the
right lower leg, and 15 • 20cm on the left side directly overlying the fracture sites. A combined plastic surgical and orthopaedic procedure was planned, consisting of open reduction and internal fixation of his fractures and bilateral latissimus dorsi flaps for cover. Definitive bony fixation was achieved and the first flap transferred to the recipient site on the left leg, with end-to-side anastomoses performed successfully. On preparing the recipient vessels for the tatissimus dorsi transfer to the right leg, a thrombus was identified within the popliteal vein, a finding which would normally have precluded free tissue transfer. Options considered included amputation of the limb, venous reconstruction using vein grafts, thrombectomy or intravascular thrombolysis. 1As there were no local alternatives to give adequate soft tissue cover, a popliteal venous thrombectomy was performed 2 using a Fogarty balloon catheter, and a 7 cm thrombus was removed from the popliteal vein. The popliteal vein was then heparinised. After good flow was established, a venotomy was performed proximal to the embolectomy site and the latissimus dorsi flap was transferred, again with an end-to-side anastomosis of the thoracodorsal to the popliteal vessels. The patient made an uneventful recovery and both flaps remained welt perfused without need for re-exploration. The patient was systemically heparinised postoperatively, and subsequently warfarinised for 3 months. There has been no clinical or radiological evidence of further deep venous thrombosis, pulmonary embolism, or any symptoms or signs of venous hypertension in the limb in which thrombectomy was performed. Now 24 months postoperatively, the patient has stable bony union with good soft tissue cover and is fully ambulant.
Discussion
Figure 1--X-ray showing bilateral lower limb injury with segmental fractures of right tibia and fibularesultingin poplitealvein thrombosis. This paper was presented at the Scottish-Irishmeetingwhich took place in Livingstone,Scotlandin October 1998.
Deep venous thrombosis of the lower limbs is frequently seen in surgical services and is a well known complication of limb trauma, with evidence of clot formation as early as 6 h after trauma. 3'4 The incidence of venous thrombosis in the acute setting is not accurately known, but it has been shown to affect 69% of major trauma patients with lower extremity orthopaedic injuries, and 77% of patients with tibial fractures. 5 This increased incidence is likely to be related to a combination of direct vessel wall trauma, stasis and local tissue hypoxia. 3'4
Giant inguinoscrotal hernia repair
525 3. Thomas DE Pathogenesis of venous thrombosis. In: Bloom AL, Thomas DE eds. Haemostasis and Thrombosis. Edinburgh: Churchill Livingstone, 1987: 767-78. 4. Hirsh J, Weitz JI. Venous thromboembolism. In: Hoffman R, ed. Hematology: basic principles and practice. New York: Churchill Livingstone, 1990: 1829-42. 5. Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous thromboembolism after major trauma. N Engl J Med 1994; 331: 1601-6. 6. Godina M. Selection of Recipient Vessels in the Lower Leg for Microvascular Flap Transfer, Marko Godina a Thesis. Ljubljana: University of Ljubljana, 1991. 7. Benacquista T, Kasabian AK, Karp NS. The fate of lower extremities with failed free flaps. Plast Reconstr Surg 1996; 98: 834-42. 8. Fuchs JCA, Hagen PO. Long-term fate of autologous vein grafts. In: Serafin D, Buncke HJ Jr, Sabiston DC Jr, Powell DG, eds. Microsurgical Composite Tissue Transplantation. St. Louis: Mosby, 1979: 90-107. 9. Suominen S, Asko-Seljavaara S. Free flap failures. Microsurgery 1995; 16: 396-9.
No cases of successful free tissue transfer following thrombectomy in recipient vessels have previously been described. There are no guidelines for the management of a patient with established deep venous thrombosis at the time of free tissue transfer. Veins and arteries within the zone of injury are known to be less suitable recipient vessels. 6 Free flap failure in the context of lower limb trauma is c o m m o n and leads to a high amputation rate. 7 Autologous vein grafts are the best replacement of small vessels but distinct pathological changes occur which may affect graft function. 8 The exact rate of thrombosis is uncertain but has been estimated to be 42% in aorto-coronary bypass, and is felt to be higher when used in lower extremities. 5 The use of vein grafts also correlates with immediate vascular complications. 9 The use of anticoagulants following free flap transfer increases the complication rate to 50%. 7 The treatment options in a patient with an open fracture requiring free tissue transfer, whose only recipient vessel is thrombosed, are limited and a high risk of flap failure must be anticipated. We would like to present venous thrombectomy as a potential treatment option which proved successful on this occasion.
Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA.
References
Smart B. Watson FRCS(Plast) lan Taggart FRCS(Plast), Consultant Plastic Surgeon
1. Husni EA. Venous reconstructive procedures. In DeWeese JA, ed. Rob and Smith's Operative Surgery: vascular surgery. London: Butterworths, 1985: 334-41. 2. DeWeese JA. Venous thrombectomy.In DeWeese JA, ed. Rob and Smith's Operative Surgery: vascular surgery. London: Butterworths, 1985: 318-24.
The Authors Odhran P. Shelley FRCSI
West of Scotland Regional Plastic Surgery,Trauma and Burns Unit, Glasgow Royal Infirmary, Glasgow G4 0SF, UK. Correspondence to Mr Ian Taggart. Paper received 16 April 1999. Accepted 10 May 2000, after revision.
BritishJournalofPlasticSurgery(2000),53
9 2000The BritishAssociationof PlasticSurgeons DOI: 10.1054/bjps.2000.3383
Repair of a giant inguinoscrotal hernia E V. Mehendale, K. O. Taams and A. N. Kingsnorth*
Department of Plastic Surgery and *Department of General Surgery, Derriford Hospital, Plymouth, UK SUMMARY. We present a case of a long-standing, giant inguinoscrotal hernia extending to the patient's knees, complicated by intestinal obstruction. Initial management involved conservative treatment of the intestinal obstruction and optimising the patient's general condition. Surgical treatment included debulking the contents of the hernia sac by performing a right hemicolectomy and a small bowel resection, and reconstruction of the abdominal wall using Marlex mesh and a tensor fasciae latae flap. Although abdominal wall reconstruction for massive ventral or incisional herniae is well reported, inguinoscrotal herniae of this magnitude are much rarer and pose additional problems, which are discussed in this paper. 9 2000 The British Association of Plastic Surgeons K e y w o r d s : giant inguinoscrotal hernia, abdominal wall reconstruction, tensor fasciae latae flap.
Giant inguinoscrotal herniae have been defined as those that extend below the midpoint of the inner thigh in the standing position. 1 A number of reconstructive techniques have been reported for the treatment of massive ventral herniae, including tissue expansion, 2 'components separation'3 and preoperative pneumoperitoneum with or
without the use of synthetic mesh. 4,5 However, treatment of the considerably less common, giant inguinoscrotal hernia is less frequently reported. 1'6'7 Although there are similarities in the management o f both types of herniae, giant inguinoscrotal herniae present specific problems that are illustrated by this case report.