Single-Stage versus Two-Stage Arteriovenous Loop Microsurgical Reconstruction: An Evidence Based Review of the Literature and Analysis of Institutional Experience
Rebecca Knackstedt, MD/PhD, Rachel Aliotta, MD, Risal Djohan, MD, Brian Gastman, MD, Graham Schwarz, MD, Mark Hendrickson, MD, Raffi Gurunluoglu, MD.
Cleveland Clinic, Cleveland, OH, USA.
AV loop grafts can be constructed to create vascular conduits for free flaps when no recipient site vessels are available. Case series and reports have discussed single versus two-staged reconstruction; however, there remains no consensus on which method is most efficacious or safest.
A systematic review of the literature AV loops for microsurgical flaps was conducted. For our institutional data, a retrospective chart review was conducted for patients who underwent single or two-stage AV loop free flap reconstruction with any staff surgeon in the department of plastic surgery at our institution.
Systematic Literature Review
Literature review yielded 18 papers with 222 patients who underwent single-staged reconstruction and 16 papers with 114 patients who underwent delayed reconstruction. Six included both single and delayed reconstruction. Since 2005, our institution performed thirteen AV loops, four as single-stage and nine as two-stage, for free flap reconstruction. AV loop length was recorded for six patients, for whom the average length was 33.83 cm. Timing of delay ranged from three to fourteen days. There were four acute loop acute failures due to thrombosis requiring intervention; one single stage and three delayed stage. All failures except one were salvageable and successful reconstruction was performed.
The literature review and our institutional experience suggest that utilizing a delayed AV loop results in a greater complication rate. The mechanism of increased thrombosis rate, or if there is a threshold for a thrombotic event to occur have yet to be determined.
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