BACKGROUND: There is a perception that the use of interpositional vein grafts in microsurgery is associated with higher anastomotic and flap failure rates, but it is not clear whether failures are caused by poor planning or the emergent use of vein grafts.

METHODS: In an attempt to test the hypothesis that "well-planned" vein interposition grafts do not increase the risk of flap failure, a retrospective review of all vein grafts performed in our institution over the last ten years was undertaken.

RESULTS: A total of 112 vein grafts were performed in the course of 62 free tissue transfers. Most of these (99/112) occurred in head and neck reconstructions and were the focus of the study. Factors that might contribute to flap failure (radiation therapy, previous surgery, age, flap choice, recipient vessels, length and type of vein graft) were subjected to a univariate and multivariate analysis to determine whether they were associated with failure. Vein graft use was also separated into a well-planned or anticipated group (defined by graft harvest before flap pedicle division, n=30), an unanticipated group (vein grafts harvested after flap pedicle division, n=50), and a reoperative salvage group (harvested following a return to the operating room, n=19). Vein grafts to arteries (n=49) were analyzed separately from vein grafts to veins (n=50). Well-planned venous vein grafts had a significantly (p<0.05) lower thrombosis rate (0/14, 0%) than those which were unanticipated (2/27, 7.4%), or used during reoperative salvage (4/9, 44.4%). Overall, the use of vein grafts was associated with a much higher flap success rate (91%) than has been previously reported. Those which were well planned were associated with failure rates (1.8%) similar to non-vein grafted free flaps. Flap choice, the presence of radiation therapy, previous surgery, length of vein graft, recipient vessels, and age did not influence flap success or failure, either as a single factor or when analyzed by logistic regression.

CONCLUSION: Vein grafts were associated with a higher flap loss rate when the grafts were used in a salvage or emergent situation. In contrast, when the vein grafts were well planned, flap success rates were similar to those in non-vein grafted flaps. This study demonstrates that, despite additional micro-anastomoses, interpositional vein grafts can be used with no increase in flap failure rate.