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Free-flap distal arteriovenous fistula: when to close it?

A distal arteriovenous fistula was created secondarily in an innervated radial forearm free flap, to salvage the neophallus in three female-to-male transsexuals. This resulted in permanent edema and an arterial thrill in the neophallus. The arteriovenous fistulas were closed after 6 weeks to 20 months. Acute endothelial damage with risk of thrombosis, due to ischemia and exposure to arterial blood pressure, may be expected to have been repaired 4 to 6 weeks after arterialization of the veins. Intimal thickening will have started by then, but a subsequent decrease in vascular luminal diameter may still be expected to be reversible. The authors conclude that ligation of the distal arteriovenous fistula may safely be performed some 6 weeks after the salvage procedure.