Microsurgical Arterial Anastomosis in Severe Arteriosclerosis Patients

INTRODUCTION Arterial calcification can be observed in diabetes, kidney disease, and hypertension; in this case, however, the calcification affects the medial layer of the arterial wall and does not associate with plaque formation. This form of arterial calcification can increase blood pressure and the risk of heart and kidney failure.1,2 Since calcifications and the fragile lining of the blood vessels can hamper the insertion of a needle, patients with arteriosclerosis can pose difficulties for microsurgeons, especially during arterial anastomosis. CASE PRESENTATION A 71-year-old woman developed oropharyngeal cancer and oropharyngeal resection was conducted by a head and neck surgeon. The patient’s medical history included diabetes mellitus and chronic renal failure that had required hemodialysis for 16 years. After oropharyngectomy, the oropharynx was reconstructed with a free anterolateral thigh (ALT) flap by a plastic surgeon. The choice of the ALT flap and the nature of the resection meant that vascular anastomosis was conducted with the lateral femoral circumflex artery in the flap and the recipient lingual artery. First of all, we prepared long recipient vessels and long flap vascular pedicles. Second, to avoid damaging the fragile artery on the ALT flap, we did not apply a vascular clamp before anastomosis. Third, the arteries were anastomosed with an interrupted suture using 9-0 nylon and particular care was paid to prevent damage to the lining of the arteries (see Videos 1 and 2). (See Video 1 [online], which displays tips for conducting successful anastomosis of heavily calcified arteries. Long recipient and donor arteries should be prepared so that the parts with the fewest lesions can be selected for anastomosis. The vascular clamps should also be used on places with few calcified sites and, if possible, not used on the flap artery.) (See Video 2 [online], which displays the procedure of arterial anastomosis. The lining of the artery is very fragile. When inserting the needle from the adventitia of the artery, make sure that it is passed through to the lining of the artery. When ligating the thread, apply appropriate tension so as not to break the lining of artery.) {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"displays tips for conducting successful anastomosis of heavily calcified arteries. Long recipient and donor arteries should be prepared so that the parts with the fewest lesions can be selected for anastomosis. The vascular clamps should also be used on places with few calcified sites and, if possible, not used on the flap artery.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_3u3iutwb"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2","caption":"displays the procedure of arterial anastomosis. The lining of the artery is very fragile. When inserting the needle from the adventitia of the artery, make sure that it is passed through to the lining of the artery. When ligating the thread, apply appropriate tension so as not to break the lining of artery.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_lwou894a"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} TIPS Arteriosclerosis can significantly complicate arterial anastomosis. This is particularly true when severe calcified arteriosclerotic lesions are present, which is often the case for arteries in the extremities.1,2 Although surgeons should generally avoid performing vascular anastomosis in such settings, the patient’s condition may make such hesitation moot.3–5 Our case illustrates several precautions. First, the surgeon should select for anastomosis the parts of the recipient and flap arteries that have the fewest atherosclerotic and calcified intimal lesions. Second, the vascular clamps should be placed on areas that have the fewest calcifications. In such cases, the lightest and smallest but adequate clamps are useful for these arteries (see Video 1 [online]). Third, since the lining of the artery is very fragile and can be separated by the suturing procedure, it is important to ensure that the needle passes as atraumatically as possible from the adventitia of the artery through to the lining of the artery. Force should be applied so that the needle advances according to the curvature of the needle. Fourth, when ligating the thread, ensure that sufficient tension is applied. Fifth, the blood vessels should be positioned with the assistant’s forceps so that the anastomosis can be performed as easily as possible (see Video 2 [online]). These tips are likely to improve vascular anastomosis outcomes in patients with severe arteriosclerosis.