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EFFECT OF ANASTOMOSIS AND GEOMETRY OF VESSEL

CURVATURE ON BLOOD FLOW VELOCITY AND PATENCY
IN MICROVESSELS
WING YUNG CHEUNG,1 FENG ZHANG, M.D., Ph.D.,1,2
URS BOSCH, M.D.,2 HARRY J. BUNCKE, M.D.,2 and
WILLIAM C. LINEAWEAVER, M.D.1*

The effect of the geometry of the vessel and the number of
anastomoses on the blood flow was studied. Four different
shapes of the vessel were constructed by using a 6-cm-long
double vein graft model with three anastomoses: (1) an alpha
loop, (2) an omega loop, (3) a sigmoid curve, and (4) straight.
Blood flow was measured by an ultrasound Doppler flowmeter. The result showed no alternation in blood flow across
different geometry and through three patent microanastomoses. However, six out of seven vein grafts were thrombosed
at 24 hr postoperative due to vascular kinks. This model

demonstrates potential sites of kinking at the dissection end
of the femoral artery, the microanastomoses, the side
branches of the vein graft, and the adventitial adhesions.
This model is recommended to microvascular trainees for the
study of kinking and the management of redundant pedicles
and vein grafting.

The most commonly identifiable technical errors in micro-

experience is the single most important factor,1 but it is
certainly more desirable if there is a practical model of
kinking to smooth out the learning curve. The resultant
redundant vessel has been stressed by some authors to be
placed in a gentle curve with fixation.4 However, experimental study of laxity is lacking. Nevertheless, this curvature has not yet been defined. Furthermore, the effect of the
geometry of the vessel curvature to the blood flow has not
been analyzed. Therefore, it is the objective of this study to
quantify the difference of blood flow of the vessel curvature
in different geometry and number of microanatomoses using a double vein grafting model.

vascular surgery are closure under tension or twists and
kinks of the pedicle, especially with utilization of vein grafting.1,2 Salvage rate is disappointingly low when both artery
and vein are thrombosed. Pedicle laxity may be one of the
critical factors increasing the risk of kinking. Although criticism has been that laxity and microanastomoses causing
turbulence may diminish blood flow, some authors advocated an operative plan to have ‘‘too much’’ vessel length
rather than just enough. Failure to select a flap with a vascular pedicle that can comfortably reach the anticipated recipient vessels could lead to flap failure.1
Occasionally, a lax pedicle is unavoidable particularly
in head and neck reconstruction. It is commonly seen in the
free fibular osteocutaneous graft and the free jejunum graft.
Sometimes a redundant loop of interposition vein graft is
deliberately reconstructed, for example, in the intra-arterial
chemotherapy in head and neck oncology and in kidney
dialysis.3 To make the final pedicle just right without tension or laxity requires good clinical judgment. Operative

1

Division of Plastic and Reconstructive Surgery, Stanford University Medical
Center, Stanford, CA.
Department of Microsurgical Transplantation and Replantation, Davies Medical Center, San Francisco, CA.

2

Contract grant sponsor: Microsurgery Foundation of the Davies Medical Center, Kwong Wah Hospital, Hong Kong; Contract grant sponsor: Division of
Plastic and Reconstructive Surgery, Stanford University, CA.
*Correspondence to: William C. Lineaweaver, M.D., Division of Plastic and
Reconstructive Surgery, Stanford University Medical Center, NC104, Stanford,
CA 94305.
© 1997 Wiley-Liss, Inc.

© 1997 Wiley-Liss, Inc.

MICROSURGERY

17:491–494

1996

MATERIALS AND METHODS

Twenty-two Sprague-Dawley rats weighing between
400–500 g were anesthetized with intraperitoneal Phenobarbital, 50 mg/kg. All of the procedures were performed under
the National Research Council’s guidelines for the care and
use of laboratory animals.
Following general anesthesia, the lower abdomen and
groin area were shaved with an electric clipper. Transverse
inguinal incisions were made to expose bilateral femoral
and epigastric vessels. The epigastric in continuity with the
femoral vein were harvested as a graft. The femoral artery
was freed carefully to minimize vasospasm. Branches to the
gracilis muscle and the distal femoral vein were ligated. The
vein graft consisted of two segments of femoral (average 1.0
mm in diameter) and epigastric (average 0.8 mm in diam-

and 4) at different time intervals was also recorded. 2). n 4 6. The blood flow gradient along each segment of the vessel with double vein grafts (groups 1. n 4 6. recorded at 20. In addition. The experiment was divided into five groups with the microvessels placed in different geometries of vessel curvature (Fig. and 3. Bipolar cautery was not used throughout the procedure. n 4 4). Figure 1. and one from group 4) were closed with running suturing. Double vein graft model. the ‘‘omega’’ loop (group 2. Fig. Patency was checked at 20 min after vascular anastomosis with the standard strip test. . 3). n 4 22). Statistical analysis was performed using the t-test. the wounds of seven rats (two each from group 1. All of the anastomoses were performed with the standard end-to-end technique using 10-0 nylon suture under ×16–25 microscopic magnification.492 Cheung et al. The contralateral femoral artery with a single anastomosis was used as a control group (group 5. 60. The first segment was anastomosed with the epigastric vein to the femoral artery. The second segment was reversed with an end-to-end femoral venovenous anastomosis. and the ‘‘straight’’ (group 4. 3. and 180 min using the ultrasonic Doppler flowmeter (Transonic Flowprobe. Intraluminal heparin was applied for cleaning the vessel ends. the ‘‘alpha’’ loop. Probe 1R293D). 1). 2. Fig. The microvessels placed in different geometry of vessel curvature. n 4 6). eter) veins between the transected femoral artery forming a 6-cm-long loop. This arrangement minimized size discrepancies between the vein graft and the artery. 2. The blood flow across these four geometries of vessels and the control group was Figure 2. These rats were kept 24 hr for patency and flow examination. the ‘‘sigmoid’’ curve (group 3. There were no intervening valves detected in this segment of vein. The epigastric vein of the second segment was anastomosed to the distal femoral artery. Lidocaine was used when vasospasm was observed. Four geometries were constructed using the double epigastric vein graft model with three microanastomoses: the ‘‘alpha’’ loop (group 1.

The vessel was also likely to kink when there was incomplete clearance of the adventitia. Patency Rates of Vein Graftings in Different Geometries 20 Minutes After Surgery* Group n Patent graft Patency rate (%) Control Alpha Omega Sigmoid Straight 22 8 9 8 4 22 6 6 6 4 100 75 67 75 100 *P > 0. and also likely to imply that the number of anastomoses creating turbulence would decrease blood flow. Our model in the rat groin was not suitable for long-term studies. proximal vein graft. 7. In this one case. recruitment of arteriovenous shunts. 6. DISCUSSION The fundamental properties in fluid mechanics are summarized in Bernoulli’s priciples. it was important to note that fixation of the curvature was extremely important and usually critical in clinical settings.5 Despite the fact that the condition of frictionless fluid is not found in living models. The disproportional increase of flow may be related to the opening up of collateral venous outflow. The potential sites of kinking of the vessel were readily demonstrated in this double vein graft model. The blood flow was more dependent on the final curvature without a kink or twist rather than the geometry per se. the effect of the curvature geometry and its resultant resistance to blood flow was shown not to be significant in this model with no significant drop of blood flow passing through three patent microanastomoses. This posed another important clinical issue in using pedicle monitoring devices and its risk of disturbing the flow of the vessel.3.14% in control. It is generally accepted that fluid energy is dissipated and laxity diminishes blood flow. In all double vein grafting groups (groups 1.Anastomosis and Geometry on Blood Flow and Patency 493 Table 1. and 4). Compared with the proximal blood flow. 2.05). the velocity of flow of a liquid is inversely proportional to the cross-sectional area of the tube and the viscosity of the fluid. Figure 3. According to Poiseuille’s Law. The blood flow change rates (distal flow/proximal flow) were 1. The dissection end of the femoral artery was a weak point for kinking. venovenous microanastomoses. the blood flow was significantly increased compared with the flow at 180 min after anastomosis.6. sigmoid. Only one of the seven vein grafts withstood compression in the limited space of the groin in this study. The blood flow gradient along each vasculer section from the patent vessel is also shown in Figure 4. There was no significant difference of blood flow between sections of the vessel at 20 and 180 min after anastomosis. and distal artery) at different time intervals is shown at Figure 4.85. In view of the mobility of the redundant vessel. The thrombosed vein grafts were observed to be kinked in the compressed space of the inguinal area due to abduction of the hind limb of the animal. or the resolution of va- . All these potential sites of kinking were readily reproduced in changing the geometry of the vessel loop. Especially. The mean blood flow at proximal and distal to vein grafts of each group from 20 to 180 min is shown in Table 2.99. Dilation of the site at femoral vein-to-femoral vein anastomosis was observed.05. 3. RESULTS The patency rate of this double vein graft 20 min after surgery is shown in Table 1. major variables associated with fluid energy loss are identified to be turbulence and resistance. The reading of the blood flow at each measurement in each group was slightly increased after anastomosis. Double vein graft model.5 This vein graft model showed a gradual increase of blood flow after the procedure. a kink would be manifested following the restoration of blood flow. and 4. Only one (from group 4) out of seven vein graftings remained patent. the ‘‘omega’’ loop. the mean blood flow gradient along each vascular segment (proximal artery. Sites of kinking were identified at the side branches of the vein grafts. The microanastomoses and the ligated side branches of the vein graft were also sensitive to twist and kink. when the axis was twisted and the microanastomoses were performed under torsion. Inadequate mobilization of the vessel would lead to a kink. and the fibrinous adhesions. and straight groups.93. Twists in vessel or graft will spiral downstream to the first fixed point where blockage occurs. Methods of fixation that may overcome external forces kinking onto the vessels definitely deserve further investigation. alpha. distal vein graft. 2. omega. proximal and distal end of the femoral artery. Blood flow varied in the individual rat.7 However. the distal flow of each group was not significantly decreased (P > 0.

Buchbinder D. Acland RD: Microvascular surgical experimental thrombosis model: Rationale and design (discussion).032 0. Lam LK. 6. J Reconstr Microsurg 12:121–126. Walker R: Mechanical evaluation of anastomotic tension and patency in arteries.183 0.9 In conclusion.05 >0. 3.02 1. Buncke GM.93 2. REFERENCES 1.05 >0.047 0. Table 2.468 0. Gould JS: The effect of venous flow alterations upon patency of rat femoral vein anastomoses. Plast Surg Forum 13:28–29. 5. Mean Blood Flow at Proximal and Distal to Vein Grafts of Each Group From 20 to 180 Minutes Group Control Alpha Omega Sigmoid Straight Proximal flow ± SD (ml/min) Distal flow ± SD (ml/min) Flow change (ml/min) Percentage P value 0. 7.593 ± 0. Cooley BC.787 ± 0. . Philadelphia Saunders.85 7.546 ± 0. Arch Otolaryngol Head Neck Surg 115:954–960. Vickery C.05 >0.3 4. sospasm. Siko P. Biller HF: Geometry of the vascular pedicle in free tissue transfers to the head and neck.05 >0. Fung YC: Rheology of blood vessels in diabetes.119 0. Lineaweaver WC. Ho CM. Alpert BS. Weinberg H. Further study is required to clarify these observations since the study number was small and the rheology of blood vessel is complex. Lineaweaver WC.483 ± 0. Choi TK. Plast Reconstr Surg 83:873–874. Urken ML.268 0. 1992.14 >0.012 0. 1993.467 ± 0. Arch Otolaryngol Head Neck Surg 119:608–611.219 0. Buncke HJ: Vein grafting in microsurgical transplantation. 1989. Zhang F.803 ± 0. 1992. Microsurgery 13:138–142.8 The wider segment of the vein graft and slower blood flow in this segment were observed in our study. Biorheology 29:443–457.463 ± 0. in Vascular Surgery.435 ± 0. Khouri RK: Avoiding free flap failure. 1996. this study showed that blood flow velocity in microvessels was not affected by the vessel curvature geometry.119 0. 1989. Clin Plast Surg 19:773–781. 1989.494 Cheung et al.468 0.05 Figure 4.180 0.191 0. 1992. 8. 4. This double vein graft model was a reproducible model for the study of kinking and a practical laboratory exercise to learn the management of a redundant pedicle. Lam KH: Regional chemotherapy for recurrent squamous head and neck cancers through a saphenous vein interposition graft. 1990. 2. Mean blood flow gradient along each segment at different time interval (ml/min). Buntic R.99 6.016 0. 9.203 0. and that three patent microanastomoses did not affect blood flow in situ on short observation. Wei WI. Sumner DS: Essential hemodynamic principles. Liu SQ. It has been shown that the vein only regained 60% of the original diameter at 24 hr.520 ± 0.508 ± 0. Oliva A. Yim K.