Microvascular errors of technique: a systematic review

Victor Esanu; Elisa Marziali; Oana Gaspar; Stefan Agoston; Teona Carciumaru; Alexandra Stoia; Claudia Paun; Horatiu A Colosi; George Dindelegan; Clemens Dirven; Torstein R Meling; Dalibor Vasilic; Victor Volovici

doi:10.1007/s00701-026-06810-w

Microvascular errors of technique: a systematic review

Victor Esanu, Elisa Marziali, Oana Gaspar, Stefan Agoston, Teona Carciumaru, Alexandra Stoia, Claudia Paun, Horatiu A Colosi, George Dindelegan, Clemens Dirven, Torstein R Meling, Dalibor Vasilic, Victor Volovici^*

^*Corresponding author for this work

Department of Neurosurgery

Abstract

INTRODUCTION: Microvascular procedures demand exceptional precision and are prone to technical errors that compromise outcomes. Performance improves fastest when errors are identified, measured, and corrected early during training. Error-based learning has become an essential part of microsurgical training, highlighting the importance of identifying and learning from mistakes to improve performance. This review aimed to systematically search the literature on all microsurgical errors and categorize them by operative phases.

MATERIALS AND METHODS: A structured literature search was conducted across Medline, Embase, and Web of Science databases, following PRISMA guidelines. Two reviewers independently screened records and extracted data in duplicate. Articles were included if they evaluated microvascular anastomoses with vessels less than 2 mm in diameter, and if microsurgical errors were detailed along with their impact on outcomes, in particular on anastomotic patency. Given the heterogeneity of the data, a SWiM-style (Synthesis Without Meta-analysis) narrative synthesis was used.

RESULTS: A total of 34 studies met the inclusion criteria. Errors were categorized as pre-operative, intra-operative, and post-operative. Intra-operative errors were the most frequently reported. Back-wall stitches, uneven lumens, and excessive suture tension were consistently associated with reduced patency. Several validated scoring tools (e.g., ALI, MARS10, OSATS) were identified as effective in quantifying errors and guiding feedback in training settings.

CONCLUSION: Microvascular anastomosis errors span all phases of the microsurgical procedure and significantly affect anastomotic success. This review offers a structured taxonomy of errors and underscores the importance of error-based learning and assessment in microsurgical training. Standardized error classification may enhance training programs, accelerating the acquisition of microsurgical skills along the learning curve and improving clinical outcomes.

Original language	English
Article number	65
Journal	Acta Neurochirurgica
Volume	168
Issue number	1
ISSN	0001-6268
DOIs	https://doi.org/10.1007/s00701-026-06810-w
Publication status	Published - 8 Mar 2026

Keywords

Cerebrovascular bypass
Microvascular anastomosis
Technique errors

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title = "Microvascular errors of technique: a systematic review",

abstract = "INTRODUCTION: Microvascular procedures demand exceptional precision and are prone to technical errors that compromise outcomes. Performance improves fastest when errors are identified, measured, and corrected early during training. Error-based learning has become an essential part of microsurgical training, highlighting the importance of identifying and learning from mistakes to improve performance. This review aimed to systematically search the literature on all microsurgical errors and categorize them by operative phases.MATERIALS AND METHODS: A structured literature search was conducted across Medline, Embase, and Web of Science databases, following PRISMA guidelines. Two reviewers independently screened records and extracted data in duplicate. Articles were included if they evaluated microvascular anastomoses with vessels less than 2 mm in diameter, and if microsurgical errors were detailed along with their impact on outcomes, in particular on anastomotic patency. Given the heterogeneity of the data, a SWiM-style (Synthesis Without Meta-analysis) narrative synthesis was used.RESULTS: A total of 34 studies met the inclusion criteria. Errors were categorized as pre-operative, intra-operative, and post-operative. Intra-operative errors were the most frequently reported. Back-wall stitches, uneven lumens, and excessive suture tension were consistently associated with reduced patency. Several validated scoring tools (e.g., ALI, MARS10, OSATS) were identified as effective in quantifying errors and guiding feedback in training settings.CONCLUSION: Microvascular anastomosis errors span all phases of the microsurgical procedure and significantly affect anastomotic success. This review offers a structured taxonomy of errors and underscores the importance of error-based learning and assessment in microsurgical training. Standardized error classification may enhance training programs, accelerating the acquisition of microsurgical skills along the learning curve and improving clinical outcomes.",

keywords = "Cerebrovascular bypass, Microvascular anastomosis, Technique errors",

author = "Victor Esanu and Elisa Marziali and Oana Gaspar and Stefan Agoston and Teona Carciumaru and Alexandra Stoia and Claudia Paun and Colosi, \{Horatiu A\} and George Dindelegan and Clemens Dirven and Meling, \{Torstein R\} and Dalibor Vasilic and Victor Volovici",

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doi = "10.1007/s00701-026-06810-w",

language = "English",

volume = "168",

journal = "Acta Neurochirurgica",

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TY - JOUR

T1 - Microvascular errors of technique

T2 - a systematic review

AU - Esanu, Victor

AU - Marziali, Elisa

AU - Gaspar, Oana

AU - Agoston, Stefan

AU - Carciumaru, Teona

AU - Stoia, Alexandra

AU - Paun, Claudia

AU - Colosi, Horatiu A

AU - Dindelegan, George

AU - Dirven, Clemens

AU - Meling, Torstein R

AU - Vasilic, Dalibor

AU - Volovici, Victor

PY - 2026/3/8

Y1 - 2026/3/8

N2 - INTRODUCTION: Microvascular procedures demand exceptional precision and are prone to technical errors that compromise outcomes. Performance improves fastest when errors are identified, measured, and corrected early during training. Error-based learning has become an essential part of microsurgical training, highlighting the importance of identifying and learning from mistakes to improve performance. This review aimed to systematically search the literature on all microsurgical errors and categorize them by operative phases.MATERIALS AND METHODS: A structured literature search was conducted across Medline, Embase, and Web of Science databases, following PRISMA guidelines. Two reviewers independently screened records and extracted data in duplicate. Articles were included if they evaluated microvascular anastomoses with vessels less than 2 mm in diameter, and if microsurgical errors were detailed along with their impact on outcomes, in particular on anastomotic patency. Given the heterogeneity of the data, a SWiM-style (Synthesis Without Meta-analysis) narrative synthesis was used.RESULTS: A total of 34 studies met the inclusion criteria. Errors were categorized as pre-operative, intra-operative, and post-operative. Intra-operative errors were the most frequently reported. Back-wall stitches, uneven lumens, and excessive suture tension were consistently associated with reduced patency. Several validated scoring tools (e.g., ALI, MARS10, OSATS) were identified as effective in quantifying errors and guiding feedback in training settings.CONCLUSION: Microvascular anastomosis errors span all phases of the microsurgical procedure and significantly affect anastomotic success. This review offers a structured taxonomy of errors and underscores the importance of error-based learning and assessment in microsurgical training. Standardized error classification may enhance training programs, accelerating the acquisition of microsurgical skills along the learning curve and improving clinical outcomes.

AB - INTRODUCTION: Microvascular procedures demand exceptional precision and are prone to technical errors that compromise outcomes. Performance improves fastest when errors are identified, measured, and corrected early during training. Error-based learning has become an essential part of microsurgical training, highlighting the importance of identifying and learning from mistakes to improve performance. This review aimed to systematically search the literature on all microsurgical errors and categorize them by operative phases.MATERIALS AND METHODS: A structured literature search was conducted across Medline, Embase, and Web of Science databases, following PRISMA guidelines. Two reviewers independently screened records and extracted data in duplicate. Articles were included if they evaluated microvascular anastomoses with vessels less than 2 mm in diameter, and if microsurgical errors were detailed along with their impact on outcomes, in particular on anastomotic patency. Given the heterogeneity of the data, a SWiM-style (Synthesis Without Meta-analysis) narrative synthesis was used.RESULTS: A total of 34 studies met the inclusion criteria. Errors were categorized as pre-operative, intra-operative, and post-operative. Intra-operative errors were the most frequently reported. Back-wall stitches, uneven lumens, and excessive suture tension were consistently associated with reduced patency. Several validated scoring tools (e.g., ALI, MARS10, OSATS) were identified as effective in quantifying errors and guiding feedback in training settings.CONCLUSION: Microvascular anastomosis errors span all phases of the microsurgical procedure and significantly affect anastomotic success. This review offers a structured taxonomy of errors and underscores the importance of error-based learning and assessment in microsurgical training. Standardized error classification may enhance training programs, accelerating the acquisition of microsurgical skills along the learning curve and improving clinical outcomes.

KW - Cerebrovascular bypass

KW - Microvascular anastomosis

KW - Technique errors

U2 - 10.1007/s00701-026-06810-w

DO - 10.1007/s00701-026-06810-w

M3 - Review

C2 - 41795717

SN - 0001-6268

VL - 168

JO - Acta Neurochirurgica

JF - Acta Neurochirurgica

IS - 1

M1 - 65

ER -

Microvascular errors of technique: a systematic review

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