LAUSR

Dear Sirs, Kinking and compression of the vascular pedicle is one of the most common causes leading to compromise of the blood flow and eventual loss of a free flap (Cheung, Zhang, Bosch, Buncke, & Lineaweaver, 1996; Kim, Kim, & Kim, 2016; Williams, French, & Lalonde, 2004). Predisposing factors include anatomic areas prone to excessive movement, effect of gravity, redundant pedicle, and length mismatch between the artery and the vein. Veins and vein grafts are especially predisposed due to the intrinsic weakness of their walls and tendency to engorge and elongate after restoration of the blood flow. Strategical positioning, cushioning with fat pads, muscle or fascia, microsurgical fixation of the vessel wall are some of the commonly employed, but of questionable efficacy, strategies as they may themselves predispose to compression. Tissue sealants have also been used, but they come at an additional cost (Kim et al., in press). We have used split vein grafts as “splints” to flatten sharp curves along the pedicle and reinforce the resistance of the vessel to compression. An appropriate length of donor vein can be harvested solely for this purpose or a remnant of greater saphenous vein graft can be employed. In our experience, saphenous vein is ideal due to its wall thickness. However, any piece of redundant vessel with suitable thickness and dimensions could be adapted for this purpose. The vein is split longitudinally and wrapped as a cuff around the area prone to kinking. The cuff can envelop the “inner vessel” either partially or completely (Figure 1a). The two edges of the venous cuff are reapproximated with fine microvascular sutures while avoiding compression of the “inner vessel.”