Distinguishing Venous Outflow Insufficiency from Ischemia–Reperfusion Injury Using a Hydro-Manometer: A Case Series

Year 2026, Volume: 18 Issue: 1, 83 - 87, 24.03.2026

Onur Çetin , Sinan Kılıç , Abdullah Yener İnce , Mehmet Kürşat Yılmaz , Fatih Parmaksızoğlu

https://doi.org/10.18521/ktd.1871635

https://izlik.org/JA42LT77FJ

Abstract

Aim: Venous insufficiency is a cause of failure in microsurgical replantation and free flap surgery and may be difficult to distinguish intraoperatively from ischemia–reperfusion injury. This study aims to introduce a simple, low-cost, and quantitative intraoperative method—the Hydro-Manometer technique—for assessing venous drainage capacity under physiological pressure conditions.
Material and Methods: This retrospective case series included seven patients treated between 2024 and 2025 who demonstrated clinically relevant venous drainage pathology. The Hydro-Manometer technique was applied intraoperatively in cases showing compromised tissue perfusion despite technically patent arterial and venous anastomoses. Venous drainage capacity was evaluated using a hydrostatic saline column corresponding to physiological venular pressure (20 cmH₂O).
Results: In all cases, arterial and venous anastomoses were confirmed to be patent intraoperatively. Venous thrombosis was identified and treated with thrombectomy in six patients. In one patient, the Hydro-Manometer revealed insufficient venous drainage capacity due to proximal venous pathology, which was successfully managed with venous grafting. All free flaps and replanted tissues survived, with no cases of postoperative venous thrombosis or tissue necrosis during follow-up.
Conclusion: The Hydro-Manometer provides an objective, quantitative, and easily applicable intraoperative assessment of venous drainage capacity in microsurgical procedures. By facilitating differentiation between venous outflow insufficiency and ischemia–reperfusion injury, this method may improve intraoperative decision-making and help prevent avoidable tissue loss.

Keywords

Microsurgery , venous drainage , free flap , replantation

Ethical Statement

Institutional ethics committee approval was obtained from Istanbul Medipol University Ethics Comittee prior to data collection. File Date 08/07/2025; File Number: E-10840098-202.3.02-4430

Supporting Institution

This research received no external funding.

Thanks

The author/authors do not wish to acknowledge any individual or institution.

References

• 1. Muntean MV, Muntean V, Ardelean F, Georgescu A. Dynamic perfusion assessment during perforator flap surgery: an up-to-date. Clujul Medical. 2015;88(3):293-7. doi:10.15386/cjmed-484.
• 2. Boissiere F, Gandolfi S, Riot S, Kerfant N, Jenzeri A, Hendriks S, et al. Flap venous congestion and salvage techniques: a systematic literature review. Plast Reconstr Surg Glob Open. 2021;9(1):e3327. doi:10.1097/GOX.0000000000003327.
• 3. Smit JM, Negenborn VL, Jansen SM, Jaspers ME, de Vries R, Heymans MW, et al. Intraoperative evaluation of perfusion in free flap surgery: a systematic review and meta‐analysis. Microsurgery. 2018;38(7):804–18. doi:10.1002/micr.30320.
• 4. Ko E, Song YJ, Choe K, Park Y, Yang S, Lim CH. The effects of intravenous fluid viscosity on the accuracy of intravenous infusion flow regulators. J Korean Med Sci. 2022;37(9):e71. doi:10.3346/jkms.2022.37.e71.
• 5. Levick JR, Michel CC. Microvascular fluid exchange and the revised Starling principle. Cardiovasc Res. 2010;87(2):198–210. doi:10.1093/cvr/cvq062.
• 6. Barrett KE, Barman SM, Brooks HL, Yuan J. Blood as a circulatory fluid & the dynamics of blood & lymph flow. In: Barrett KE, Barman SM, Brooks HL, Yuan J, editors. Ganong's review of medical physiology. 26th ed., New York: McGraw-Hill Education; 2019. p. 557-88.
• 7. Hall JE, Hall ME. Overview of the circulation: pressure, flow, and resistance. In: Hall JE, Hall ME, editors. Guyton and hall textbook of medical physiology. 14th ed., Philadelphia: Elsevier; 2021. p. 171-81.
• 8. Vaienti L, Gazzola R, Benanti E, Leone F, Marchesi A, Parodi PC, et al. Failure by congestion of pedicled and free flaps for reconstruction of lower limbs after trauma: the role of negative-pressure wound therapy. J Orthop Traumatol. 2013;14(3):213–7. doi:10.1007/s10195-013-0236-0.
• 9. Borle F, Heymans S, Dhole S, Jaiswal D. Delayed partial venous insufficiency of free flap: to ıntervene or not? Cureus. 2023;15(12):e51068. doi:10.7759/cureus.51068.
• 10. Yalcin NG, Bruscino-Raiola F, Ferris S. Proximal trauma increases risk of venous thrombosis in soft tissue reconstruction of open lower limb fractures. Front Surg. 2020;7:574498. doi:10.3389/fsurg.2020.574498.
• 11. Bigdeli AK, Gazyakan E, Schmidt VJ, Hernekamp FJ, Harhaus L, Henzler T, et al. Indocyanine green fluorescence for free-flap perfusion imaging revisited: advanced decision making by virtual perfusion reality in visionsense fusion imaging angiography. Surg Innov. 2016;23(3):249–60. doi:10.1177/1553350615610651.
• 12. Holm C, Mayr M, Höfter E, Dornseifer U, Ninkovic M. Assessment of the patency of microvascular anastomoses using microscope‐integrated near‐infrared angiography: a preliminary study. Microsurgery. 2009;29(7):509–14. doi:10.1002/micr.20645.
• 13. Pestana IA, Zenn MR. Correlation between abdominal perforator vessels identified with preoperative CT angiography and intraoperative fluorescent angiography in the microsurgical breast reconstruction patient. Ann Plast Surg. 2014;72(6):S144–9. doi:10.1097/SAP.0000000000000104.
• 14. Valerio I, Green JM 3rd, Sacks JM, Thomas S, Sabino J, Acarturk TO. Vascularized osseous flaps and assessing their bipartate perfusion pattern via intraoperative fluorescence angiography. J Reconstr Microsurg. 2015;31(1):45–53. doi:10.1055/s-0034-1383821.
• 15. Beier JP, Horch RE, Arkudas A, Dragu A, Schmitz M, Kneser U. Decision-making in DIEP and ms-TRAM flaps: the potential role for a combined laser Doppler spectrophotometry system. J Plastic Reconstr Aesthet Surg. 2013;66(1):73–9. doi:10.1016/j.bjps.2012.08.040.
• 16. Callender NA, Høiseth LØ, Hisdal J. External negative pressure transiently reduces intravenous pressure and augments the arteriovenous pressure gradient in the affected limb segment. PloS One. 2024;19(12):e0315231. doi:10.1371/journal.pone.0315231.
• 17. Hope-Ross M, Yannuzzi LA, Gragoudas ES, Guyer DR, Slakter JS, Sorenson JA, et al. Adverse reactions due to indocyanine green. Ophthalmology. 1994;101(3):529–33. doi:10.1016/s0161-6420(94)31303-0.
• 18. Beckler AD, Ezzat WH, Seth R, Nabili V, Blackwell KE. Assessment of fibula flap skin perfusion in patients undergoing oromandibular reconstruction. JAMA Facial Plast Surg. 2015;17(6):422-6. doi:10.1001/jamafacial.2015.0961.
• 19. Clinton MS, Sepka RS, Bristol D, Pederson WC, Barwick WJ, Serafin D, et al. Establishment of normal ranges of laser Doppler blood flow in autologous tissue transplants. Plast Reconstr Surg. 1991;87(2):299–309. doi:10.1097/00006534-199102000-00012.
• 20. Granger DN, Kvietys PR. Reperfusion injury and reactive oxygen species: the evolution of a concept. Redox Biol. 2015;6:524–51. doi:10.1016/j.redox.2015.08.020.
• 21. Güler MC, Tanyeli A, Ekinci Akdemir FN, Eraslan E, Özbek Şebin S, Güzel Erdoğan D, et al. An overview of ischemia-reperfusion injury: review on oxidative stress and inflammatory response. Eurasian J Med. 2022;54(Suppl1):62–5. doi:10.5152/eurasianjmed.2022.22293.