Arterial Anastomosis to Injured Vessels: Outcomes in Lower Extremity Trauma Reconstruction

Although traditional teaching advocates that microsurgical anastomoses should be performed to uninjured vessels outside the zone of injury (ZOI), there is no defined way to assess the extent of the ZOI, and uninjured vessels may not be available. To evaluate the complications ascribed to the ZOI and injured vessels, outcomes between arterial anastomoses fashioned from within the ZOI versus noninjured recipient vessels were compared.

A retrospective review was conducted of adult patients who required lower extremity free flap (FF) reconstruction from 2016 to 2024. Injury to the recipient artery (transection, avulsion, or thrombosis) was determined by intraoperative assessment or preoperative computed tomography angiography. The primary outcome, complications attributed to the arterial anastomosis, was a composite variable defined as return to the operating room during the index hospitalization for arterial thrombosis, partial flap loss, and/or total flap loss.

A total of 285 cases met our inclusion criteria, with 87 (30.5%) FF arterial anastomoses performed to an injured recipient artery. Of the 285 cases in this study, 20 (7.0%) required operating room takeback for arterial thrombosis and/or partial/total flap loss. However, there was no significant difference between the incidence of these complications for FFs anastomosed to injured (6.9%) versus noninjured (7.1%) recipient arteries (P > 0.9).

Although healthy vessels outside the ZOI are preferred for lower extremity reconstruction, the selection of recipient vessels can be guided by surgeon expertise and microsurgical technique when they are unavailable, broadening the options for limb salvage.