Venous Coupler Versus Hand-Sewn Anastomoses in Autologous Breast Reconstruction: A Systematic Review and Pooled Analysis

Purpose: Anastomotic microvascular devices have become increasingly popular in reconstructive microsurgery due to their high patency rates, reduced operative times, and comparable flap complication rates compared to traditional hand-sewn (HS) anastomoses. Several single-institution case series have demonstrated favorable outcomes with venous coupler (VC) use in autologous breast reconstruction. The purpose of this study is to systematically evaluate the literature on the use of VC and HS venous anastomosis in autologous breast reconstruction with regards to operative efficiency and clinical outcomes. 

Methods: A systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Three electronic databases (PubMed, MEDLINE, and EMBASE) were queried with the search terms “breast reconstruction,” “free flap,” “microvascular anastomotic coupler,” “anastomotic device,” and “venous coupler.” Studies were included if they indicated venous anastomosis method. Studies including non-breast categories of reconstruction (e.g., lower extremity, head and neck, etc.) were only included if breast reconstruction outcomes were explicitly reported. Anastomotic time and surgical outcomes, including venous complications, partial and total flap loss (due to both venous and non-venous etiologies) and re-operation and salvage rates were collected. Outcomes were pooled, and p-values were computed using Fischer’s exact test, with a value <0.05 considered statistically significant.

Results: A total of 15 studies encompassing 5,471 free flaps for breast reconstruction met inclusion criteria. Of these, four studies directly compared VC and HS cases, seven reported on VC cases only, and the remaining four reported on HS cases, only. The median publication year of the VC and HS studies was 2009 and 2008.5, respectively. The VC device was used in 2,979 (54.4%) flaps, while 2,492 flaps (45.6%) utilized HS anastomoses. Deep inferior epigastric perforator (DIEP) flaps and transverse rectus abdominis muscle (TRAM) flaps were the most common reconstructive techniques in the VC group, accounting for 47.6% and 42.0% of all flaps performed, respectively. In the HS group, TRAM flaps comprised the vast majority of free flaps (72.6%). Mean anastomosis time was reported in five VC studies (4.46 minutes, 1,573 flaps) and only in one HS study (21 minutes, 887 flaps). Venous complications occurred in 143 flaps (2.61%), overall. There was a significantly decreased venous complication rate in the VC group as compared to the HS group (1.54% vs. 3.89%, p<0.0001). Venous complications were further categorized by etiology (e.g., thrombosis, mechanical kinking, insufficiency, etc.). Thrombosis accounted for the majority of venous complications in both the VC and HS groups (89.1% and 96.9%, respectively). The VC group experienced significantly reduced total flap failure rate (0.38% vs. 1.18%, p=0.0032) and return to the operating room (1.58% vs. 3.90%, p<0.0001) as compared to the HS group. Salvage rates in the VC and HS groups were 81.6% and 73.0%, respectively (p= 0.7576).

Conclusion: Evolutions in both microvascular technique and technology have improved safety and outcomes in autologous breast reconstruction. Our study demonstrates the benefits of using VC as opposed to HS anastomosis in this patient cohort due to its efficiency of use, favorable venous complication rate, reoperation rate, and overall flap survival rate.