Saphenous vein graft with mechanisms of “anchor-pipe” and pressure “step-down” to ensure the use of carotid artery as recipient for free flap transfer in vessels-depleted neck

The “anchor-pipe” technique utilizes an interposed great saphe- nous vein (SV) graft (with at least one internal valve) which is sutured (“anchor”) with the back-wall-first technique, using 7/0 Nylon single needle suture, in end-to-side fashion (Figure 1a). The flap artery is then anastomosed with 9/0 Nylon micro-suture to the distal SV (“pipe”). The CA arteriotomy is adjusted according to the caliber of the flap artery to enable a natural transition pressure (“step-down”). All interrupted sutures must be performed with optimal intimal interposi- tion and full thickness bites, according to the wall thickness of each vessel wall without adventitiectomy. It can be used in lack of other recipient vessels or when recent therapeutic radiation present damage to regional vessels, which may prove a potential threat and increased rates of late thrombosis because of fibrosis and increased interstitial connective tissue swelling between tunica intima and media.