Anterograde Intra-Arterial Urokinase Injection for Salvaging Fibular Free Flap

Abstract

We present a case of a 57-year-old male patient who presented with squamous cell carcinoma on his mouth floor with cervical and mandibular metastases. Wide glossectomy with intergonial mandibular ostectomy, and sequential reconstruction using fibular osteomyocutaneous free flap were planned. When the anastomosis between the peroneal artery of the fibular free flap and the right lingual artery was performed, no venous flow was observed at the vena comitans. Then re-anastomosis followed by topical application of papaverine and lidocaine was attempted. However, the blood supply was not recovered. Warm saline irrigation over 30 minutes was also useless. Microvascular thromboses of donor vessels were clinically suspected, so a solution of 100,000 units of urokinase was infused once through a 26-gauge angiocatheter inserted into the recipient artery just at the arterial anastomotic site, until the solution gushed out through the flap vena comitans. Immediately after the application of urokinase, arterial flow and venous return were restored. There were no complications during the follow-up period of 11 months. We believe that vibrating injuries from the reciprocating saw during osteotomies and flap insetting might be the cause of microvascular thromboses. The use of urokinase may provide a viable option for the treatment of suspicious intraoperative arterial thrombosis.

Anterograde injection of low-dose urokinase salvages free anterolateral thigh flap

“…[ 1 ] These procedures are effective for treating external compression, tension, twisting, or kinking of the pedicle vessels, but not for treating microvascular thrombosis. [ 4 , 7 ]…”

“…Its half-life is short (only about 15 min). [ 4 ] In clinical practice, urokinase has been used to vessel and catheter clotting. However, the systemic spread of urokinase can cause major health concerns.…”

“…The lowest dosage which has been reported is 100,000 IU. [ 4 ] Effectiveness of low-dose urokinase on dialysis catheter had been proved. [ 5 ] Yet few relevant cases have been reported thus far, safe and effective urokinase doses and delivery procedures for free flap salvage remain unclear.…”

Eptifibatide Salvage of Arterial Anastomotic Thrombosis in Lower Extremity Free Flap Reconstruction: A Case Report

“…3 Urokinase and alteplase are therapeutic options that have been used to successfully salvage free flap reconstruction. 4 Eptifibatide (Integrilin, Millennium Pharmaceuticals, Cambridge, MA) is a drug of the glycoprotein IIb/IIIa-inhibitor class. We present a case of successful salvage with a partial superior latissimus dorsi free muscle flap in a patient with thrombocytosis and intraoperative arterial anastomotic thrombosis using intra-and postoperative administration of eptifibatide combined with heparin infusion.…”

Using Incidental Side Branches of Vessels for Intraoperative Cannulation and Irrigation of the Microvascular Anastomosis

“…Also, it is available to irrigate postanastomotic vessels in circumstances of the suspicion of microthrombi including the vessels inside the flap. 5 Another advantage of using side branches is that they allow standard angiocatheters to pass from proximal end to the distal end of the vessels to act as a stent which helps anastomosis especially if there is a calibre discrepancy. Using stents or intravascular thermosensitive gels without any microclamps were reported to be useful in microvascular anastomosis without any trauma on vessel edges.…”