The suitability of end-to-side microvascular anastomosis in free flap transfer for limb reconstruction

End-to-end (ETE) microvascular anastomosis used in free flap transfer for limb reconstruction often requires the sacrifice of a major artery, which may aggravate distal circulation of the limb. The purpose of this study is to investigate the relationship between the type of microvascular anastomosis and the survival of free flaps, and to highlight the end-to-side (ETS) anastomotic technique when facing vascular anatomic variations.

Between 1999 and 2008, a retrospective review was conducted by a single microsurgeon on 203 patients who underwent free flap reconstruction for limb reconstruction. We examined the clinical course of 209 arterial and 308 venous anastomoses. ETS anastomoses were performed for 99 vessels, whereas ETE anastomoses for 418 vessels. The distribution and outcome of ETS and ETE anastomoses were compared.

One arterial thrombosis (1.15%, 1/87) was recorded in ETS anastomosis group, whereas none (0%, 0/122) was recorded in ETE anastomosis group (P = 0.419). Four venous thromboses (1.35%, 4/296) were found in ETE group, whereas none was found in ETS group (0%, 0/12). There was no statistically significant difference between the 2 anastomotic techniques. Six cases with double pedicles needed ETS anastomosis for 2 arterial and 2 venous reconstructions. Flap survival rate in ETS arterial group was 98.8%, whereas in ETE arterial group, it was 100%.

ETS microvascular anastomosis has an equivalent flap survival rate as compared with ETE microvascular anastomosis. ETS anastomosis should be considered first when facing vessel size discrepancy and for preserving the major arteries of limbs.