Intermittent Short Saphenous Vein Phlebotomy: An Effective Technique of Relieving Venous Congestion in the Distally Based Sural Artery Flap

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Venous congestion is the main cause of failure in the distally based sural artery flap. Herein, we present our technique of phlebotomy to relieve flap congestion. Venous blood is intermittently drained via an exteriorized segment of the short saphenous vein until flap circulation normalizes.

Methods and Materials:

From 2000 to 2005, 34 distally based sural artery flaps were performed. In all patients, an extra 5 cm of the short saphenous vein was incorporated with the flap during harvest. Fourteen flaps were noted to be congested after inset. In 2 patients, supercharging was performed. In the remaining 12 patients, intermittent phlebotomy was performed through an externalized segment of the short saphenous vein on the operating table and hourly thereafter until venous congestion improved.


All flaps survived. The mean duration of phlebotomy was 30 hours, and mean blood loss in the first 24 hours was estimated to be 94 mL. The color of the flap was noted improved gradually over this period as it established a more efficient venous drainage.


Our approach of providing an additional venous outlet for congested flaps contributed to the favorable survival rate noted in this series. Intermittent phlebotomy was a simple and effective way to relieve venous congestion during the immediate postoperative period. As oscillating avalvular veins hypertrophied and multiplied during the ensuing 24–48 hours, venous circulation improved and the short saphenous vein spontaneously stopped draining. Phlebotomy improved flap survival and was a valuable temporizing measure to prevent critical congestion in flaps adapting to a new circulatory pattern.

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