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Venous Flaps for Revascularization and Soft-tissue Coverage in Traumatic Hand Injuries: A Comprehensive Review of the Literature
John Roberts, BS, MD; Christopher T. Haley, BS; Logan W. Carr, MD; Sebastian M. Brooke, MD; Randy M. Hauck, MD; Brett F. Michelotti, MD
Hershey Medical Center, Hershey, PA

Background: The use of venous flaps for simultaneous revascularization and coverage of soft tissue defects has been documented in the literature for over 30 years. The aim of this study was to conduct a comprehensive review of the literature and to perform meta-analysis of the outcomes of venous flaps in traumatic hand injuries.
Methods: A literature search of PubMed was performed with emphasis on venous flap use in traumatic hand injuries. The following search terms were combined as appropriate: vein graft, revascularization, venous flow through flap, arterialized venous flap, bypass, replantation, amputation, avulsion, trauma, injury, amputate, finger, hand and thumb. The initial search returned 1777 articles of which 43 met inclusion criteria. Articles were included if they demonstrated primary data and the use of a venous flap for revascularization in traumatic injuries distal to the wrist.
Results: The included articles described 563 venous flaps. The average age of subjects was 36.5 years, and the likelihood of partial loss of the flap increased with increasing age (p=0.018). The average number of anastomoses per flap was 2.34 with a range of 1 to 8. The anastomosis types were comprised of 452 arterio-venous flaps (AFV) with arterial inflow and venous outflow, 63 arterio-arterial flaps (AFA), 37 veno-venous flaps (VFV), and 7 retrograde venous flaps (FV). Concurrent analysis of all anastomosis types revealed no significant difference with respect to the following: complete flap survival (81.9% AFV, 77.8% AFA, 67.6% VFV, 88.8% FV; p=0.26), partial flap loss (13.0% AFV, 19.0% AFA, 21.6% VFV, 11.1% FV; p=0.46), and total flap failure (2.9% AFV, 3.2% AFA, 10.8% VFV, 0% FV; p=0.139). A flap covering multiple fingers had a higher rate of partial loss than a flap covering a single finger (46% vs. 14%, p=0.016). Flap size of 0-10 cm2 resulted in a higher rate of complete failure (6.5%; p=0.02) compared to a flap size of 10-25 cm2 (1.1%) and those greater than 25 cm2 (2.5%); however, flap size had no significant effect on partial loss (p=0.256).
Conclusions: Older patients have a higher likelihood of partial venous flap loss, but the type of anastomosis has no effect on flap survival. If multiple digits require coverage, a single flap per digit should be considered. Flaps smaller than 10 cm2 had the highest incidence of total flap failure; however, medium to large venous flaps had few total flap failures and can be used reliably for traumatic defects of the hand.

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