Secondary ischemia caused by venous or arterial occlusion shows differential effects on myocutaneous island flap survival and muscle ATP levels
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Secondary ischemia caused by venous or arterial occlusion shows differential effects on myocutaneous island flap survival and muscle ATP levels. / Hauge, E M; Balling, E; Hartmund, T; Hjortdal, V E.
In: Plastic and Reconstructive Surgery, Vol. 99, No. 3, 03.1997, p. 825-33.Research output: Contribution to journal › Journal article › Research › peer-review
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T1 - Secondary ischemia caused by venous or arterial occlusion shows differential effects on myocutaneous island flap survival and muscle ATP levels
AU - Hauge, E M
AU - Balling, E
AU - Hartmund, T
AU - Hjortdal, V E
PY - 1997/3
Y1 - 1997/3
N2 - Ischemia-reperfusion injury is one of the major problems in reconstructive microsurgery. The ischemic insult may be due to an occlusion of either the artery or the vein. Clinical observations have suggested that flap survival is more sensitive to venous stasis than to arterial ischemia. The current study evaluated the viability of the myocutaneous rectus abdominis flap following secondary arterial or venous occlusion and its possible dependency on tissue metabolites and length of the preceding reperfusion period. Forty-eight bilateral 5 X 10 cm myocutaneous rectus abdominis flaps were elevated in 24 pigs and exposed to consecutive periods of primary ischemia (2 hours), reperfusion (1, 4, 8, and 12 hours), and secondary pedicle occlusion (6, 8, 10, 12, 14, or 16 hours) of arterial or venous origin. Muscle adenosine triphosphate (ATP) and glucose-6-phosphate (G6P) were assessed immediately after flap elevation, at the end of primary ischemia, after reperfusion, and at the end of secondary ischemia. Flap viability was assessed 5 days after the operation. Secondary venous occlusion resulted in reduced survival rates as compared with arterial occlusion (9 of 24 versus 20 of 24; p < 0.01), although the average ATP content was higher in flaps subjected to venous stasis [median (25 to 75) percentiles, 3.7 (1.7 to 7.1) micromol/gm protein] than in those subjected to arterial ischemia 1.2 (0.8 to 1.8 micromol/gm protein) (p < 0.01). During reperfusion, muscle ATP decreased from 28.5 (17.9 to 36.6) micromol/gm protein to 15.4 (7.4 to 24.9) micromol/gm protein (p < 0.01) and glucose-6-phosphate from 7.6 (4.1 to 11.6) micromol/gm protein to 1.0 (0.5 to 4.1) micromol/gm protein (p < 0.01). Still, flap survival following secondary arterial ischemia was improved by increasing the reperfusion time from 1 to 8 hours (p < 0.05). No effect of reperfusion time was seen on viability after venous stasis. In conclusion, despite poorer flap survival, venous stasis was less detrimental to tissue ATP level, suggesting that the continued inflow may have supplied substrates for glycolysis. Furthermore, the larger blood volume may have accumulated the glycolytic waste products. After reperfusion, the recovery of aerobic metabolism was far from complete, and cellular glycolytic substrates were nearly exhausted. However, prolongation of the reperfusion time preceding secondary arterial ischemia improved flap survival.
AB - Ischemia-reperfusion injury is one of the major problems in reconstructive microsurgery. The ischemic insult may be due to an occlusion of either the artery or the vein. Clinical observations have suggested that flap survival is more sensitive to venous stasis than to arterial ischemia. The current study evaluated the viability of the myocutaneous rectus abdominis flap following secondary arterial or venous occlusion and its possible dependency on tissue metabolites and length of the preceding reperfusion period. Forty-eight bilateral 5 X 10 cm myocutaneous rectus abdominis flaps were elevated in 24 pigs and exposed to consecutive periods of primary ischemia (2 hours), reperfusion (1, 4, 8, and 12 hours), and secondary pedicle occlusion (6, 8, 10, 12, 14, or 16 hours) of arterial or venous origin. Muscle adenosine triphosphate (ATP) and glucose-6-phosphate (G6P) were assessed immediately after flap elevation, at the end of primary ischemia, after reperfusion, and at the end of secondary ischemia. Flap viability was assessed 5 days after the operation. Secondary venous occlusion resulted in reduced survival rates as compared with arterial occlusion (9 of 24 versus 20 of 24; p < 0.01), although the average ATP content was higher in flaps subjected to venous stasis [median (25 to 75) percentiles, 3.7 (1.7 to 7.1) micromol/gm protein] than in those subjected to arterial ischemia 1.2 (0.8 to 1.8 micromol/gm protein) (p < 0.01). During reperfusion, muscle ATP decreased from 28.5 (17.9 to 36.6) micromol/gm protein to 15.4 (7.4 to 24.9) micromol/gm protein (p < 0.01) and glucose-6-phosphate from 7.6 (4.1 to 11.6) micromol/gm protein to 1.0 (0.5 to 4.1) micromol/gm protein (p < 0.01). Still, flap survival following secondary arterial ischemia was improved by increasing the reperfusion time from 1 to 8 hours (p < 0.05). No effect of reperfusion time was seen on viability after venous stasis. In conclusion, despite poorer flap survival, venous stasis was less detrimental to tissue ATP level, suggesting that the continued inflow may have supplied substrates for glycolysis. Furthermore, the larger blood volume may have accumulated the glycolytic waste products. After reperfusion, the recovery of aerobic metabolism was far from complete, and cellular glycolytic substrates were nearly exhausted. However, prolongation of the reperfusion time preceding secondary arterial ischemia improved flap survival.
KW - Adenosine Triphosphate/metabolism
KW - Animals
KW - Arteries/physiopathology
KW - Glucose-6-Phosphate/metabolism
KW - Graft Survival/physiology
KW - Rectus Abdominis/metabolism
KW - Reperfusion Injury/etiology
KW - Surgical Flaps/blood supply
KW - Swine
KW - Time Factors
KW - Veins/physiopathology
U2 - 10.1097/00006534-199703000-00032
DO - 10.1097/00006534-199703000-00032
M3 - Journal article
C2 - 9047203
VL - 99
SP - 825
EP - 833
JO - Plastic and Reconstructive Surgery
JF - Plastic and Reconstructive Surgery
SN - 0032-1052
IS - 3
ER -
ID: 243522266