The use of vein graft arteriovenous fistulae in conjuction with free tissue transfer was first described in 1982. This technique facilitates anastomosis away from a zone of injury, shortens flap ischemia time and serves to ascertain recipient vessel function.

Historical debate has centered upon whether a one-stage procedure with immediate fistula division or a two-stage delayed division (days to weeks later)is optimal. We have reviewed our series and the published literature to clarify this issue.

In our series six fistulae were created for six flaps in five patients. These were one-stage procedures with immediate use of the arteriovenous fistula. All flaps survived.

Literature review produced sixty-five flaps performed with immediate use of the fistula and sixty-four flaps with two-stage delays. Reported failure rates were 6 and 15 percent respectively. Meta-analysis of numerous other factors including age, sex, etiology, location, donor site, fistula length and anticoagulation protocol was also undertaken. No statistically significant effect on flap survival was found. However, comparison of fistula thrombosis rates between the immediate and delayed groups did reach statistical significance, 7.5 and 27 percent respectively. (p<0.006)

We conclude that immediate use of the arteriovenous fistula is the optimal strategy. There is no demonstrable advantage to delay.