The shunt-restricted arterialized venous flap for hand/digit reconstruction: Enhanced perfusion, decreased congestion, and improved reliability

Background:: Arterialized venous flaps can be useful for hand/digit reconstruction, providing very thin skin coverage. However, their popularity has been limited by concerns over poor peripheral perfusion and severe congestion, which may be to be due to unrestricted arteriovenous shunting and pressurization of the efferent vein. To mitigate these problems, we design our flaps to restrict shunting. This report describes our clinical experience with these techniques. Methods:: A consecutive series of 15 flaps was reviewed. All flaps were transferred with antegrade flow. Shunt restriction was achieved in one of the following ways, according to the flap's venous pattern: (1) two parallel veins (II-pattern): use of separate veins for inflow and outflow; (2) two parallel veins with connecting branch (H-pattern): as for II-pattern, with ligation of connecting branch; (3) branching vein (Y/λ-pattern): ligation of one branch near bifurcation, with use of that branch for outflow and other segment for inflow (or vice versa); and (4) one continuous vein (I-pattern): ligation at midpoint. Laser Doppler flowmetry was used to compare flap perfusion with and without shunt restriction in two patients. Results:: All flaps survived entirely. Color, turgor, temperature, and capillary refill mimicked conventional arterial flaps, facilitating postoperative monitoring. Six flaps demonstrated mild-to-moderate venous congestion at the afferent end, with some developing epidermolysis but no full-thickness loss. Intraoperative flowmetry showed enhanced perfusion in the flap's periphery when shunting was restricted. Conclusions:: Restriction of arteriovenous shunting enhances peripheral perfusion and decreases congestion of venous flaps, thereby improving reliability and utility for hand/digit reconstruction.