October 2018 #PRSJournalClub Wrap-Up: Interposition Vein Grafting in Head and Neck Free Flap Reconstruction

by Geoffrey E. Hespe, MD (@GeoffreyHespeMD)

Plastic Surgery Resident, University of Michigan


Welcome everyone to this month’s recap for #PRSJournalClub on #FacebookLive for the month of October where we discussed a recent article by Drs. Marco Maricevich, Lawrence Lin, Jun Liu, Edward Change and Matthew Hanasono entitled “Interposition Vein Grafting in Head and Neck Free Flap Reconstruction.” The full discussion can be found on the PRS Facebook page.

You are able to read the article for free on the PRS website here.

The article was first discussed by the current Resident Ambassadors to the PRS Editorial Board Francesco Egro (@francescoegro), Nikki Phillips (@drnikkiphillips) and Ira Savetsky (@irasavetskymd) with special guest Dr. Gordon Lee.

Listen to the podcast discussion here:

Finally, in a new “Plastic Surgery Minutes” video, Dr. Roy Kim discusses this article one of the authors Dr. Hanasono. The short video can be found here:

In this article, Maricevich and colleagues examine the use of interposition vein grafts in the setting of head and neck oncologic reconstruction. There is limited data in the literature regarding this topic due to its infrequent use and has demonstrated mixed results. Because of this many surgeons are cautious to use vein grafts due to the increased risk of flap compromise. In this retrospective study they looked at a total of 3240 free flaps for head and neck oncologic reconstruction from the years 2005 to 2015 in 3072 patients. In this cohort there were 241 free flaps (7.4%) were an interposition vein graft was used. The main objectives of this study were to look at the rate of flap loss with and without vein grafts, examine the effects of vein grafts in this setting and finally in cases of flap loss to examine the vein graft’s role in this failure.

What the authors found was that their overall rate of flap survival was 98.5%. When analyzing the data they found that both groups were not identical with interposition grafts being used more frequently in the setting of radiation, chemotherapy, prior neck dissection, prior or multiple free flaps and osteoradionecrosis. When examining interposition vein grafts association with flap compromise they determined that it was significantly higher (14.5% vs. 3.4%) compared to without vein grafts. Vein grafting was also associated with a higher failure rate and a lower salvage rate when compared to flaps without vein grafting (6.6% vs. 1.1% and 54.3% vs. 66.3%) respectively. Overall, though, the free flap survival rate in their vein grafting cohort was 93.4% compared to 98.9% in flaps without vein grafting.

Next they looked at variables associated with flap compromise to try and identify causes, the authors found that along with vein grafting, hypertension, prior radio-/chemotherapy and prior neck dissection were also associated with high rates of flap compromise. When looking at univariate analysis for flap loss, their data demonstrated that vein grafting along with diabetes and chemotherapy increased the risk of loss. They found no difference with vein graft donor site in flap compromise or loss. To further investigate the association of vein grafts and flap loss the authors looked at every case of flap loss to try and determine the cause. Interestingly, what the authors found was that there were no cases of thrombus that was located only in the vein and no cases of technical error resulting in thrombosis suggesting that vein grafts were likely not prothrombotic and that additional anastomoses were not the case of flap loss.

Maricevich and colleagues should be applauded for this very interesting article that helps to better characterize the use vein grafting in head and neck reconstruction. Although the authors demonstrate that there is an increased risk of flap compromise and loss in flaps using vein grafts, they argue that a flap rate loss of 93.4% in this group is still an acceptable success rate. The cohort of flaps undergoing vein grafting had a significant increase in factors that can make surgery more challenging (radio-/chemotherapy, osteonecrosis, previous free flaps, previous neck dissection) thus making native vessels poor recipients for primary anastomosis. The authors recommend that ideally, free flap reconstruction should be planned on a case-by-case manner to prevent the need for vein grafting but if in a given situation a vein graft is necessary it can be a reasonable option for successful reconstruction given the high overall success rate. 

As always, lots of great questions were asked of the authors from this paper by practicing plastic surgeons and residents and the authors provided deeper incites into the findings of their paper on October 28th for #PRSJournalClub on #FacebookLive. I have provided a summary of the top Q/A’s below for your viewing.  We are excited to continue this great resource.

Looking forward to seeing you at the next #PRSJournalClub and Go Blue!

Cheers,

Geoff


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