Arterialised venous loops and complex flap reconstruction: can silicone and Doppler monitoring make them safer?

Abstract

Arteriovenous loops (AVL) of Corlett are used to provide recipient vessels for complex microsurgical reconstructions in vessel depleted lower limbs. They can be prone to thrombosis, injury during re-dissection, and possible steal phenomenon. We report an approach to improve safety and decrease dissection time in a delayed complex lower limb reconstruction. A 49-year-old male was referred for non-union of a severely comminuted and compound femoral fracture. A vascularised double-barrel fibula flap was planned with a two-team approach. Despite negative bone scans and pre-operative blood tests, infected femoral callus was found intraoperatively. The raised flap was wrapped in silicone sheets to ease re-dissection. At the second reconstructive attempt, after antibiotic therapy, the silicone-wrapped recipient vein was found thrombosed. A delayed reconstruction with an AVL was executed. The contralateral long saphenous vein was harvested and anastomosed end-to-side to the superficial femoral artery and end-to-end to the ipsilateral great saphenous vein close to the saphenofemoral junction. The loop was wrapped in silicone to prevent over-dilatation of the vein and to prevent adherence to tissues for subsequent dissection. The loop was matured for 4 weeks during which Doppler ultrasonography revealed an arterial stenosis requiring balloon angioplasty. Division of the loop and final free fibula flap transfer occurred with no postoperative complications. The use of silicone sheeting has not been previously described to protect the recipient vessels, to facilitate re-operation, and to restrict AVL dilatation secondary to arterial forces. Doppler ultrasonography has also not been described to monitor loop safety. Combined AVL with silicone sheeting and Doppler monitoring improved the speed and safety in this two-stage AVL procedure.

Level of evidence: Level V, therapeutic study.