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In free-flap surgery for limb trauma, anastomosis not only of the arteries but also of the veins is important to maintain flap blood flow. For this purpose, it is also important to identify a good vein that has an appropriate caliber and sufficient flow at the donor site. Here, we used a vein visualization device (Accuvein®) and obtained good results.
A 72-year-old man sustained an open fracture to the left tibia and fibula during a fall from a height. Debridement and external fixation were performed on day 1 of the injury, and open reduction and external fixation (ORIF) of the fibula, on day 7 of the injury. ORIF of the tibia was cancelled because the skin around the medial condyle was necrotized. Fix-and-flap surgery with an anterolateral thigh (ALT) flap was performed on postoperative day 18. We harvested this flap with 2 accompanying veins as pedicles. We selected the recipient artery and vein as the dorsalis pedis artery and its accompanying vein identified by echo. Furthermore, another subcutaneous vein located slightly outside was identified preoperatively by use of Accuvein®. The great saphenous vein could not be used because it was damaged at the time of the injury. The skin incision line was determined so that both subcutaneous veins identified by Accuvein® and the dorsalis pedis artery could be deployed to the operative field, and end-to-end anastomosis of each of these vessels was performed. No adverse events such as congestion or ischemia were observed postoperatively, and the postoperative course was uneventful (Fig. 1).
Fig. 1A: Searching for s subcutaneous vein B: Dorsalis pedis artery, accompanying vein, and subcutaneous vein are marked C: Skin incision lines are determined D: After plating, that is, before harvesting of the free flap (ALT) E: End-to-end anastomosis was performed F: After the operation.
Veins, particularly superficial subcutaneous veins, are more likely to be injured in trauma. In such a situation, development of a thrombus, blockage, or defect of the vein may occur, making the vein unsuitable for anastomosis. On the other hand, multiple venous anastomoses are recommended for the maintenance of free-flap blood flow in trauma.
Lower limb lymphedema treated with lymphatico-venous anastomosis based on pre- and intraoperative ICG lymphography and non-contact vein visualization: a case report.
It is useful in any situation where venous exploration is required not only for mapping the veins in surgery, but also for phlebotomy. Unlike ultrasonography, Accuvein® does not depend on the skill of the examiner. Use of this equipment makes it possible to evaluate the trajectory and the diameter of the subcutaneous vein easily and widely before and while operating.
This leads to a reduction in time exploring the veins, efficient determination of the skin incision lines, and avoidance of unintentional injury during operative field deployment, with significant benefits for surgery. Another advantage of this equipment is that it is noninvasive and does not use contrast materials,
Effectiveness of AccuVein AV400 device versus ultrasound-guided cannulation of the great saphenous vein at the ankle in infants: a randomized controlled trial.
On the other hand, the drawback is that it is difficult to accurately depict when the skin is uneven or blood adheres to the surface of the skin. (498words)
Acknowledgement
We would like to thank Dr Kaoru Sasaki, Dr Yohei Yanagisawa, and Professor Mitsuru Sekido for useful discussions. We are grateful to Flaminia Miyamasu for careful grammatical revision of the manuscript.
Lower limb lymphedema treated with lymphatico-venous anastomosis based on pre- and intraoperative ICG lymphography and non-contact vein visualization: a case report.
Effectiveness of AccuVein AV400 device versus ultrasound-guided cannulation of the great saphenous vein at the ankle in infants: a randomized controlled trial.
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