Artery first and declamp it: A temporary revascularization method during microvascular anastomosis: A retrospective case series study.

[BACKGROUND] The optimal sequence of microvascular clamping during free flap transfer is yet to be established. Many surgeons are reluctant to perform temporary declamping and subsequent reclamping during microvascular anastomosis; however, we generally anastomose the artery first and temporarily declamp it before performing venous anastomosis to confirm arterial patency and ensure proper alignment of the flap veins. Herein, we aimed to retrospectively investigate the efficacy and safety of this temporary revascularization method in 126 patients who underwent microvascular head and neck reconstruction.

[METHODS] A total of 127 free flaps were transferred, with the anterolateral thigh flap (49 flaps) being the most frequently used. The internal jugular vein was the most frequently used recipient vein and end-to-side anastomoses to it were performed in 112 patients.

[RESULTS] Intraoperative reanastomosis was required because of arterial thrombosis in 5 cases (4.0%), arterial and venous thrombosis in 1 case (0.8%), injury to the flap artery distal to the anastomotic site in 1 case (0.8%), and venous twisting in 1 case (0.8%). Postoperatively, all the flaps survived without microvascular compromise.

[CONCLUSIONS] Vascular kinking or twisting of the vascular pedicle is a major cause of free flap failure. However, it is difficult to place empty vessels accurately during clamping. Nonetheless, temporary revascularization engorges the flap vein before venous anastomosis and minimizes the risk of venous kinking and twisting. According to our results, reclamping did not increase the risk of arterial thrombosis.