Creation of Superficial Temporal Arteriovenous Loop for Staged Free Tissue Transfer for Dural Coverage in the Setting of Radiation: A Case Report

Abstract

Free tissue transfer for dural coverage can be challenging for various reasons. In the case of malignancy, patients often have received significant doses of radiation to the head and neck leading to fibrosis and osteoradionecrosis. Not only will free tissue transfer need to accommodate an often large defect but will need to protect intracranial contents. Recipient vessel quality and patency is often affected by comorbidities such as diabetes mellitus and coronary artery disease and can be compounded by radiation. Due to these factors, more proximal vessels in the head and neck are often pursued but due to insufficient length, often require vein grafts or arteriovenous loops to reach the donor vessels for anastomosis. This requires larger incisions and harvesting of lengthy veins. In this study, we discuss a technique of harvesting a small dorsal hand vein, that is hidden well in a hand crease, to create an arteriovenous loop between the superficial temporal vessels. Benefits include exploration of the recipient superficial temporal vessels prior to craniectomy without creating additional incisions, readily accessible recipient vessels to reach donor vessels without harvesting lengthy vein grafts, and allowing for arterialization of the superficial temporal vein leading to decreased venous congestion and thrombosis. While this can be done in 1 stage, we perform this in 2 stages to avoid an increased number of anastomoses and increased risk of flap failure. We present the case of an elderly male with multiple comorbidities and scalp osteoradionecrosis secondary to malignancy who this technique was successfully performed on.