A Survey of Microvascular Technique Preferences Among American Head Neck Society Members

• Published in: The Laryngoscope 2024-03, Vol.134 (3), p.1265-1277
• Main Authors: Philips, Ramez, Best, Keisha A., Agarwal, Aarti, Sagheer, Hamad, Selman, Yamil, Sweeney, Larissa, Wax, Mark, Krein, Howard, Heffelfinger, Ryan, Luginbuhl, Adam, Curry, Joseph
• Format: Article
• Language: English
• Subjects: anastomosis leak; arterial plaque; flap volume; free flap; interposition graft; microvascular technique; pedicle geometry; practice length; tension; vessel mismatch
• ISSN: 0023-852X; 1531-4995; 1531-4995
• DOI: 10.1002/lary.30995

Objective To identify practices in microvascular techniques in routine and challenging scenarios. Study Design Cross‐sectional study. Methods A national survey addressing practices related to microvascular free flap reconstruction was distributed to AHNS members between October and November 2021. Results The respondents encompassed 95 microvascular surgeons. Median years of practice was 6 (interquartile range, 2–13) and median flaps per year was 35 (22–50). Common practices in arterial anastomosis included limited cleaning of artery (84.2%), use of a double approximating clamp (64.2%), and use of interrupted suture (88.4%). Common practices in venous anastomosis included limited cleaning (89.5%), downsizing the coupler (53.7%), and coupling to two independent venous systems (47.4%). In arterial anastomosis, respondents felt that kinking (50.5%) and tension (24.2%) were the riskiest challenges. Kinking was handled by loose sutures or native tissue/dissolvable biomaterial to orient pedicle. Excess tension was handled by additional dissection. With regards to associated practices, most surgeons perform anastomosis after partial inset (52.6%), give aspirin immediately postoperatively (66.3%), reserve transfusion for hemodynamic instability (69.5%), and utilize intraoperative pressors when needed (72.6%). More senior surgeons reported placing more suture to address leaks (p = 0.004) and perform end to side anastomosis on larger vein in case of venous mismatch (p = 0.012). In cases of tension, higher volume surgeons perform more extensive dissection (p = 0.035) and end to side coupling (p = 0.029). Conclusions This survey of AHNS members indicates patterns of microvascular techniques in routine and challenging scenarios. There exists a variation in approaches amongst surgeons based on volume and practice length. Level of Evidence 5 Laryngoscope, 134:1265–1277, 2024 In arterial and venous anastomosis, respondents felt that kinking was the riskiest challenge for flap failure. Kinking was handled by loose sutures or native tissue/dissolvable biomaterial to orient pedicle. Most surgeons use pressors as needed, but reserve transfusions in cases of hemodynamic instability. More senior surgeons reported placing more suture to address leaks and perform end‐to‐side anastomosis on larger vein in case of venous mismatch. In cases of tension, higher volume surgeons perform more extensive dissection and end to side coupling.