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  • Title: [Anatomical types and anastomosis methods of concomitant veins of deep inferior epigastric artery].
    Author: Song D, Li Z, Zhang Y.
    Journal: Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi; 2023 Jan 15; 37(1):41-45. PubMed ID: 36708114.
    Abstract:
    OBJECTIVE: To summarize the anatomical types of the concomitant veins of deep inferior epigastric artery and the corresponding choice of anastomosis methods, and to evaluate the indications and safety of various methods. METHODS: Between October 2015 and June 2021, 296 female patients received breast reconstruction with autologous free lower abdominal flap, including 154 cases of immediate breast reconstruction and 142 cases of delayed breast reconstruction. The average age of the patients was 36.5 years, ranged from 26 to 62 years. Unilateral free deep inferior epigastric artery perforator flap transplantation was performed in 172 cases, and unilateral free muscle-sparing rectus abdominis myocutaneous flap transplantation was performed in 124 cases. The internal thoracic vessels were selected as the recipient vessels in all cases. The length of vascular pedicle ranged from 9.5 to 13.0 cm, with an average of 11.2 cm. The concomitant veins of deep inferior epigastric artery included three anatomical types: one-branch type in 26 cases (8.8%), two-branch type in 180 cases (60.8%), and Y-shaped structure in 90 cases (30.4%). Anastomosis of inferior epigastric artery was performed with the proximal end of internal thoracic artery, while that of vein should be adjusted according to the diameter, length, wall thickness, and branches of the vein. The specific classification of venous anastomosis included: ① The sole concomitant vein of deep inferior epigastric artery was anastomosed with the internal mammary vein (26 cases); ② The two concomitant veins of deep inferior epigastric artery were anastomosed with the internal mammary vein respectively (151 cases); ③ The larger one of two concomitant veins of deep inferior epigastric artery was anastomosed with the internal mammary vein, and the other one was ligated and discarded (29 cases); ④ The two concomitant veins of deep inferior epigastric artery were Y-shaped, and the common trunk segment was directly anastomosed with the internal mammary vein (31 cases); ⑤ The smaller branch of the concomitant veins of Y-shaped structure was ligated, and the thicker branch was anastomosed with the internal mammary vein (17 cases); ⑥ The concomitant veins of Y-shaped structure were anastomosed with the internal mammary veins respectively (42 cases). RESULTS: Among the patients who underwent venous anastomosis according to scheme ④, 3 cases had venous crisis of flap after operation, of which 1 case was successfully rescued by emergency exploration; the other 2 cases had flap necrosis, of which 1 case survived after being repaired by pedicled latissimus dorsi flap, and 1 case closed the wound directly. Flaps with other venous anastomosis protocols survived completely. All 296 patients were followed up 12-70 months, with an average of 37.5 months. The reconstructed breast has good shape, good elasticity, and no skin flap contracture. The donor site of the flap only left linear scar, and the abdominal wall function was not affected. CONCLUSION: The method of direct anastomosis of concomitant veins of deep inferior epigastric artery with Y-shaped structure is relatively risky, and the vessels are prone to be twisted and compressed, leading to the occurrence of venous crisis. It can improve the safety of surgery if only one large vein is anastomosed or two veins are separated to anastomose respectively. 目的: 总结腹壁下动脉伴行静脉解剖类型及相应吻合方法选择，并评估各种方法的适应证和安全性。. 方法: 回顾分析2015年10月—2021年6月296例采用游离下腹部皮瓣移植再造乳房患者的临床资料。患者均为女性；年龄26～62岁，平均36.5岁。乳腺癌术后即刻乳房再造154例，延期乳房再造142例。172例采用单侧血管蒂游离腹壁下动脉穿支皮瓣移植，124例采用单侧血管蒂保留部分腹直肌的游离腹直肌皮瓣移植；均单纯选择胸廓内血管作为受区血管。血管蒂长度为9.5～13.0 cm，平均11.2 cm。腹壁下动脉伴行静脉包括3种解剖类型：1支型26例（8.8%），2支型180例（60.8%），Y形结构伴行静脉90例（30.4%）。动脉吻合方式均为腹壁下动脉与胸廓内动脉近心端吻合；静脉吻合方式需根据静脉管径、长度、管壁厚度以及分支情况灵活调整，主要包括：① 腹壁下动脉唯一的1支伴行静脉与胸廓内静脉吻合（26例）；② 腹壁下动脉的2支伴行静脉分别与胸廓内静脉吻合（151例）；③ 腹壁下动脉的2支伴行静脉中，粗大1支与胸廓内静脉吻合，另1支结扎弃用（29例）；④ Y形结构伴行静脉共干节段直接与胸廓内静脉吻合（31例）；⑤ Y形结构伴行静脉结扎较细的1支，将较粗的属支与胸廓内静脉吻合（17例）；⑥ Y形结构伴行静脉完全切开，分别与胸廓内静脉吻合（42例）。. 结果: 采用方案 ④ 行静脉吻合的患者中，术后有3例出现静脉危象，其中1例急诊探查挽救皮瓣成功；另2例发生皮瓣坏死，其中1例采用带蒂背阔肌皮瓣修复后顺利成活，1例直接拉拢闭合创面。采用其他静脉吻合方案的皮瓣完全成活。296例患者均获随访，随访时间12～70个月，平均37.5个月。再造乳房外形可，弹性好，无皮瓣挛缩变形。皮瓣供区仅遗留线性瘢痕，腹壁功能无影响。. 结论: Y形结构腹壁下动脉伴行静脉直接吻合方法相对风险更高，血管之间容易发生扭转和卡压，导致皮瓣静脉危象发生；改为仅吻合粗大1支或分离成2支静脉分别吻合，可提高手术安全性。.
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